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General NPI Number Information
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NPI Number | 1740888023
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Entity Type | Organization
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Legal Business Name | AGNETTA ORTHODONTICS PLLC
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Dates
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Enumeration Date | 10/09/2020
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Last Update Date | 10/09/2020
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Provider Practice Location Address
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Address Line | 6311 KINGSTON PIKE STE 26W
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City | KNOXVILLE
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State | TN
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Zip | 37919-4900
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Country | US
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Telephone | 208-761-1210
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Fax |
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Provider Business Mailing Address
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Address Line | 1205 IVES ST
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City | WATERTOWN
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State | NY
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Zip | 13601-4216
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Country | US
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Telephone | 208-761-1210
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | DR. EVAN JAMES AGNETTA
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Credential | DDS, MS
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Telephone | 208-761-1210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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