Healthcare Provider Details

I. General information

NPI: 1992832059
Provider Name (Legal Business Name): VANNI RUSS STRENTA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3914 BLANDING BLVD
JACKSONVILLE FL
32210-5413
US

IV. Provider business mailing address

3914 BLANDING BLVD
JACKSONVILLE FL
32210-5413
US

V. Phone/Fax

Practice location:
  • Phone: 904-573-9560
  • Fax: 904-573-9562
Mailing address:
  • Phone: 904-573-9560
  • Fax: 904-573-9562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN13548
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: