Provider Demographics
NPI:1689782385
Name:VANETTA, GEORGE ROBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ROBERT
Last Name:VANETTA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 A1A BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6733
Mailing Address - Country:US
Mailing Address - Phone:904-261-2980
Mailing Address - Fax:
Practice Address - Street 1:1947 CITRONA DR
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4492
Practice Address - Country:US
Practice Address - Phone:904-261-2980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00135291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN0013529OtherLICENSE NUMBER