Provider Demographics
NPI:1194803387
Name:DEBRUIN, RONALD SCOTT (DDS)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:SCOTT
Last Name:DEBRUIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 WATER TOWER RD
Mailing Address - Street 2:UNIT #2
Mailing Address - City:ENOSBURG FALLS
Mailing Address - State:VT
Mailing Address - Zip Code:05450-6097
Mailing Address - Country:US
Mailing Address - Phone:802-933-8316
Mailing Address - Fax:802-933-6555
Practice Address - Street 1:84 WATER TOWER RD
Practice Address - Street 2:UNIT #2
Practice Address - City:ENOSBURG FALLS
Practice Address - State:VT
Practice Address - Zip Code:05450-6097
Practice Address - Country:US
Practice Address - Phone:802-933-8316
Practice Address - Fax:802-933-6555
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT16-300011261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1003075Medicaid