Provider Demographics
NPI:1316096977
Name:ANTONELLI, JOHN (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ANTONELLI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 S UNIVERSITY DRIVE
Mailing Address - Street 2:NOVA SOUTHEASTERN UNIVERSITY COLLEGE OF DENTAL MEDICINE
Mailing Address - City:FORT LAUDERDALE DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-2018
Mailing Address - Country:US
Mailing Address - Phone:954-262-7348
Mailing Address - Fax:
Practice Address - Street 1:3200 S UNIVERSITY DRIVE
Practice Address - Street 2:NOVA SOUTHEASTERN UNIVERSITY COLLEGE OF DENTAL MEDICINE
Practice Address - City:FORT LAUDERDALE DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2018
Practice Address - Country:US
Practice Address - Phone:954-262-7348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTPNU053122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist