Provider Demographics
NPI:1427258631
Name:SONBOL, GEORGE A M (DDS)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:A M
Last Name:SONBOL
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 1:706 BRIGHTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2336
Mailing Address - Country:US
Mailing Address - Phone:504-919-1987
Mailing Address - Fax:
Practice Address - Street 1:4003 S NOVA RD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4922
Practice Address - Country:US
Practice Address - Phone:386-763-2000
Practice Address - Fax:386-763-2080
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014119221223G0001X
FLDN195321223G0001X
WADE000112391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5057021Medicaid