Provider Demographics
NPI:1942870654
Name:CIVITILLO, SARAH RENEA (DDS)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:RENEA
Last Name:CIVITILLO
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 1:577 STERNBERG AVE
Mailing Address - Street 2:
Mailing Address - City:FORT EUSTIS
Mailing Address - State:VA
Mailing Address - Zip Code:23604-1526
Mailing Address - Country:US
Mailing Address - Phone:757-314-7944
Mailing Address - Fax:
Practice Address - Street 1:669 MONROE AVE
Practice Address - Street 2:
Practice Address - City:FORT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-5005
Practice Address - Country:US
Practice Address - Phone:757-314-8016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-26
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12337294-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist