Provider Demographics
NPI:1417283649
Name:AGNINI, DERRY GUSHEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DERRY
Middle Name:GUSHEN
Last Name:AGNINI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-2225
Mailing Address - Country:US
Mailing Address - Phone:863-513-8112
Mailing Address - Fax:
Practice Address - Street 1:39863 HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-7802
Practice Address - Country:US
Practice Address - Phone:863-353-6867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-22
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 166471223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics