Provider Demographics
NPI:1962406215
Name:SHAFER, MICHAEL KENT (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KENT
Last Name:SHAFER
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 1:2419 GOULDEN RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-9510
Mailing Address - Country:US
Mailing Address - Phone:802-674-5999
Mailing Address - Fax:802-674-6176
Practice Address - Street 1:54 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:VT
Practice Address - Zip Code:05089-1321
Practice Address - Country:US
Practice Address - Phone:802-674-5999
Practice Address - Fax:802-674-6176
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT6921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0001952Medicaid