1487678876 NPI number — MAIN STREET FAMILY DENTISTRY, PC

Table of content: (NPI 1487678876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487678876 NPI number — MAIN STREET FAMILY DENTISTRY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN STREET FAMILY DENTISTRY, PC
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:
6
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:
1487678876
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
152 MAIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTPELIER
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-229-0690
Provider Business Mailing Address Fax Number:
802-229-4793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
152 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTPELIER
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-229-0690
Provider Business Practice Location Address Fax Number:
802-229-4793
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LANSKY
Authorized Official First Name:
CASSANDRA
Authorized Official Middle Name:
PIEPER
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
802-229-0690

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  2028 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 2062 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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