Provider Demographics
NPI:1487853644
Name:FAMILY DENTAL ASSOCIATES
Entity type:Organization
Organization Name:FAMILY DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:KOLODZEJ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:802-775-0819
Mailing Address - Street 1:4 GENERAL WING RD
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4682
Mailing Address - Country:US
Mailing Address - Phone:802-775-0819
Mailing Address - Fax:802-775-1487
Practice Address - Street 1:4 GENERAL WING RD
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4682
Practice Address - Country:US
Practice Address - Phone:802-775-0819
Practice Address - Fax:802-775-1487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT8711223G0001X
VT11121223G0001X
VT7691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTFAMI2398OtherBLUE CROSS BLUE SHIELD
VT1000430Medicaid