Provider Demographics
NPI:1871707786
Name:DR. KENNETH PALM
Entity type:Organization
Organization Name:DR. KENNETH PALM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:PALM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:802-655-5308
Mailing Address - Street 1:106 HIGH POINT CTR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-5861
Mailing Address - Country:US
Mailing Address - Phone:802-655-5308
Mailing Address - Fax:802-655-5715
Practice Address - Street 1:106 HIGH POINT CTR
Practice Address - Street 2:SUITE 100
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-5861
Practice Address - Country:US
Practice Address - Phone:802-655-5308
Practice Address - Fax:802-655-5715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT012371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1005081Medicaid
VT01237OtherSTATE DENTAL LICENSE
VT01237OtherSTATE DENTAL LICENSE