Provider Demographics
NPI:1134171010
Name:VAGNETTI, MARK (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:VAGNETTI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 WINDING RIVER LN
Mailing Address - Street 2:SUITE 302
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-3569
Mailing Address - Country:US
Mailing Address - Phone:434-260-7025
Mailing Address - Fax:
Practice Address - Street 1:320 WINDING RIVER LN
Practice Address - Street 2:SUITE 302
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-3569
Practice Address - Country:US
Practice Address - Phone:434-260-7025
Practice Address - Fax:888-980-9982
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA401410767122300000X
VA04014107671223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist