Provider Demographics
NPI:1679628382
Name:MICHAEL D. VANOVER, D.D.S., P.A.
Entity Type:Organization
Organization Name:MICHAEL D. VANOVER, D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:VANOVER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-272-2438
Mailing Address - Street 1:784 BLANDING BLVD
Mailing Address - Street 2:STE 110
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-8717
Mailing Address - Country:US
Mailing Address - Phone:904-272-2438
Mailing Address - Fax:904-272-6376
Practice Address - Street 1:784 BLANDING BLVD
Practice Address - Street 2:STE 110
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-8717
Practice Address - Country:US
Practice Address - Phone:904-272-2438
Practice Address - Fax:904-272-6376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL160881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty