Provider Demographics
NPI:1811609027
Name:DE VERNEJOUL, THIBAULT (DMD)
Entity type:Individual
Prefix:
First Name:THIBAULT
Middle Name:
Last Name:DE VERNEJOUL
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 1:2807 NE 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4570 LYONS RD STE 102
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-3483
Practice Address - Country:US
Practice Address - Phone:954-324-4764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN252011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty