Provider Demographics
NPI:1053937292
Name:MIDDLEBURY PEDIATRIC DENTISTRY, PLLC
Entity type:Organization
Organization Name:MIDDLEBURY PEDIATRIC DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:802-388-0909
Mailing Address - Street 1:132 S VILLAGE GRN
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-6900
Mailing Address - Country:US
Mailing Address - Phone:802-388-0909
Mailing Address - Fax:802-989-7095
Practice Address - Street 1:132 S VILLAGE GRN
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-6900
Practice Address - Country:US
Practice Address - Phone:802-388-0909
Practice Address - Fax:802-989-7095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1022015Medicaid