Provider Demographics
NPI:1952417503
Name:VANAELST, BRIAN TODD (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:TODD
Last Name:VANAELST
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 E FLETCHER AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4905
Mailing Address - Country:US
Mailing Address - Phone:813-988-1103
Mailing Address - Fax:352-392-3070
Practice Address - Street 1:4444 E FLETCHER AVE STE A
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4905
Practice Address - Country:US
Practice Address - Phone:813-988-1103
Practice Address - Fax:813-985-1524
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN168671223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBV8932356OtherDEA