Provider Demographics
NPI:1437369154
Name:AGNETTA, ROBERT J (DDS,MS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:AGNETTA
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 IVES ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4216
Mailing Address - Country:US
Mailing Address - Phone:315-267-6588
Mailing Address - Fax:
Practice Address - Street 1:22 DEPOT ST STE 17
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1140
Practice Address - Country:US
Practice Address - Phone:315-267-6588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDL-17661223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID820505759Medicaid