1811191158 NPI number — ALLEN BROOK COMPREHENSIVE DENTAL, P.L.C

Table of content: (NPI 1811191158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811191158 NPI number — ALLEN BROOK COMPREHENSIVE DENTAL, P.L.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALLEN BROOK COMPREHENSIVE DENTAL, P.L.C
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:
1811191158
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
303 FORTY ACRE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLISTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05495-2114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-878-0979
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 CORNERSTONE DR
Provider Second Line Business Practice Location Address:
SUITE 215
Provider Business Practice Location Address City Name:
WILLISTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05495-4012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-878-7775
Provider Business Practice Location Address Fax Number:
802-879-8388
Provider Enumeration Date:
06/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ALCALA
Authorized Official First Name:
CARMEN
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
802-878-7775

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  016-0001175 , 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)

  • Identifier: OVN0448 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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