Provider Demographics
NPI:1487769659
Name:DAVOREN, PAUL LEO (DDS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:LEO
Last Name:DAVOREN
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:PO BOX 320
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05667-0320
Mailing Address - Country:US
Mailing Address - Phone:802-454-1057
Mailing Address - Fax:802-454-8339
Practice Address - Street 1:157 TOWN AVE
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:VT
Practice Address - Zip Code:05667-0320
Practice Address - Country:US
Practice Address - Phone:802-454-1057
Practice Address - Fax:802-454-8339
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0160000796122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0002419Medicaid