Provider Demographics
NPI:1942423280
Name:VITALE, JEROME (DMD)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:
Last Name:VITALE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1343 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952
Mailing Address - Country:US
Mailing Address - Phone:772-337-1111
Mailing Address - Fax:772-337-6352
Practice Address - Street 1:1343 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952
Practice Address - Country:US
Practice Address - Phone:772-337-1111
Practice Address - Fax:772-337-6352
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN139751223G0001X
NY0433981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice