Provider Demographics
NPI:1740888023
Name:AGNETTA ORTHODONTICS PLLC
Entity type:Organization
Organization Name:AGNETTA ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:AGNETTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:208-761-1210
Mailing Address - Street 1:1205 IVES ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4216
Mailing Address - Country:US
Mailing Address - Phone:208-761-1210
Mailing Address - Fax:
Practice Address - Street 1:6311 KINGSTON PIKE STE 26W
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4900
Practice Address - Country:US
Practice Address - Phone:208-761-1210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty