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General NPI Number Information
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NPI Number | 1942423280
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Entity Type | Individual
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Provider Name | JEROME VITALE D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/11/2007
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Last Update Date | 09/06/2024
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Provider Practice Location Address
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Address Line | 1343 SE PORT ST LUCIE BLVD
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City | PORT LUCIE
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State | FL
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Zip | 34952
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Country | US
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Telephone | 772-337-1111
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Fax | 772-337-6352
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Provider Business Mailing Address
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Address Line | 1343 SE PORT ST LUCIE BLVD
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City | PORT LUCIE
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State | FL
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Zip | 34952
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Country | US
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Telephone | 772-337-1111
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Fax | 772-337-6352
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN13975
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 043398
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License Number State | NY
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