Provider Demographics
NPI:1407342546
Name:SONAVANE, SHRUTI SUSHILKUMAR (DMD)
Entity Type:Individual
Prefix:
First Name:SHRUTI
Middle Name:SUSHILKUMAR
Last Name:SONAVANE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:SHRUTI
Other - Middle Name:GANESH
Other - Last Name:HAJARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5378 BENTPINE COVE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-0837
Mailing Address - Country:US
Mailing Address - Phone:205-603-6231
Mailing Address - Fax:
Practice Address - Street 1:4906 TOWN CENTER PKWY UNIT 404
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-8594
Practice Address - Country:US
Practice Address - Phone:904-441-1568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN286551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
D019120-01OtherASPEN AMERICAN INSURANCE COMPANY