Provider Demographics
NPI:1538255864
Name:THORNTON, BRENNAN M
Entity type:Individual
Prefix:
First Name:BRENNAN
Middle Name:M
Last Name:THORNTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 STONEHILL RD
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-9521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:617 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1601
Practice Address - Country:US
Practice Address - Phone:802-864-6309
Practice Address - Fax:802-652-1087
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT160000530122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0001750Medicaid
VT160000530OtherSTATE LICENSE