Provider Demographics
NPI:1194358556
Name:LOMBARDO, COURTNEY
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:
Last Name:LOMBARDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 PROVENCE PL
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-7072
Mailing Address - Country:US
Mailing Address - Phone:561-310-1526
Mailing Address - Fax:
Practice Address - Street 1:880 37TH PL STE 101
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6597
Practice Address - Country:US
Practice Address - Phone:772-569-4424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL242191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
24219OtherLICENSE