Provider Demographics
NPI:1881706802
Name:VENEGAS, JOSE RAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:RAUL
Last Name:VENEGAS
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 1:28315 S TAMIAMI TRL
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-3209
Mailing Address - Country:US
Mailing Address - Phone:239-949-1655
Mailing Address - Fax:
Practice Address - Street 1:28315 S TAMIAMI TRL
Practice Address - Street 2:SUITE 102
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-3209
Practice Address - Country:US
Practice Address - Phone:239-949-1655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN164721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice