Gopichand Vallabhaneni
Individual provider Active NPI Dentist · Burlington, VT
NPI 1376638536 · NPPES record last updated Nov 26, 2012
Key facts
- NPI
- 1376638536
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 0160002181 (VT)
- Practice address
- 617 Riverside Ave
Burlington, VT 05401-1601 - Phone
- (802) 864-6309
- NPI assigned
- Oct 4, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in VT
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20130122000149 | VT | Practitioner - Oral Surgery | 4688827843 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Community Health Centers of Burlington Inc | Current |
Accepting new patients | |
| Community Health Centers of Burlington Inc | Current |
Accepting new patients |
Locations
617 Riverside Ave
Burlington, VT 05401
Phone (802) 264-8158
Interoperability endpoints
- gopichand.vallabhaneni.p1@direct.chcb.nextgenshare.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 0160002181 | VT | Yes |
Addresses
Primary practice location
617 Riverside Ave
Burlington, VT 05401-1601
Mailing address
617 Riverside Ave
Burlington, VT 05401-1601
Phone (802) 864-6309
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0160002181 | Other | VT | STATE LICENSE |
| 1010394 | Medicaid | VT |
Other providers in Burlington, VT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 26, 2012. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.