Provider Demographics
NPI:1619336369
Name:LEBRON, VANESSA E (DDS)
Entity Type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:E
Last Name:LEBRON
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 1:5607 NW 27TH AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33142-2826
Mailing Address - Country:US
Mailing Address - Phone:305-805-1700
Mailing Address - Fax:305-805-1715
Practice Address - Street 1:5361 NW 22ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-8035
Practice Address - Country:US
Practice Address - Phone:305-637-6400
Practice Address - Fax:305-805-1715
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-22
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21713122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018762300Medicaid