Provider Demographics
NPI:1801352604
Name:BORGENICHT, VANESSA
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:BORGENICHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7168 BEEK ST
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-6516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1507 S HIAWASSEE RD STE 209
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-5719
Practice Address - Country:US
Practice Address - Phone:407-376-4135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-17
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN26184122300000X
390200000X
FLDRPM1995390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty