Provider Demographics
NPI:1912100256
Name:MAPLE LEAF FAMILY DENTISTRY
Entity type:Organization
Organization Name:MAPLE LEAF FAMILY DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:S
Authorized Official - Last Name:EBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:802-888-5685
Mailing Address - Street 1:PO BOX 636
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05661-0636
Mailing Address - Country:US
Mailing Address - Phone:802-888-5685
Mailing Address - Fax:
Practice Address - Street 1:58 BRIGHAM STREET
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:VT
Practice Address - Zip Code:05661
Practice Address - Country:US
Practice Address - Phone:802-888-5685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016-00020381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009502Medicaid