Provider Demographics
NPI:1144593476
Name:VALANCIUS, MICHAEL S (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:VALANCIUS
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 1:11013 N DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-3801
Mailing Address - Country:US
Mailing Address - Phone:813-963-1724
Mailing Address - Fax:
Practice Address - Street 1:11013 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-3801
Practice Address - Country:US
Practice Address - Phone:813-963-1724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN97481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00256400Medicaid