Provider Demographics
NPI:1992798649
Name:VAVRUSKA, JULIE A (DMD)
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:A
Last Name:VAVRUSKA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 S US HIGHWAY 301
Mailing Address - Street 2:
Mailing Address - City:SUMTERVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:33585-5135
Mailing Address - Country:US
Mailing Address - Phone:352-793-5900
Mailing Address - Fax:352-793-6269
Practice Address - Street 1:1389 S US HIGHWAY 301
Practice Address - Street 2:
Practice Address - City:SUMTERVILLE
Practice Address - State:FL
Practice Address - Zip Code:33585-5135
Practice Address - Country:US
Practice Address - Phone:352-793-5900
Practice Address - Fax:352-793-6269
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15250122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL057724300OtherMEDICAID FEE FOR SERVICE
FL029547796OtherMEDICAID DENTAL
FL029547700OtherMEDICAID FQHC
LA680013100Medicaid
FL029547796OtherMEDICAID DENTAL