1083850374 NPI number — JEDIDIAH L JANISSE DMD AND ASSOCIATES, LTD

Table of content: (NPI 1083850374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083850374 NPI number — JEDIDIAH L JANISSE DMD AND ASSOCIATES, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEDIDIAH L JANISSE DMD AND ASSOCIATES, LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083850374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
217 MAXHAM MEADOW WAY # 10
Provider Second Line Business Mailing Address:
SUITE 4C
Provider Business Mailing Address City Name:
WOODSTOCK
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05091-1162
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-457-1903
Provider Business Mailing Address Fax Number:
802-457-3619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
217 MAXHAM MEADOW WAY # 10
Provider Second Line Business Practice Location Address:
SUITE 4C
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05091-1162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-457-1903
Provider Business Practice Location Address Fax Number:
802-457-3619
Provider Enumeration Date:
12/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JANISSE
Authorized Official First Name:
JEDIDIAH
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
802-457-1903

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  016-0002247 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QS0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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