Provider Demographics
NPI:1003044843
Name:LEBEAU, JACQUE V (DMD)
Entity Type:Individual
Prefix:
First Name:JACQUE
Middle Name:V
Last Name:LEBEAU
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 1:1401 N PALAFOX ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-2642
Mailing Address - Country:US
Mailing Address - Phone:850-434-1964
Mailing Address - Fax:850-430-4123
Practice Address - Street 1:1401 N PALAFOX ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-2642
Practice Address - Country:US
Practice Address - Phone:850-434-1964
Practice Address - Fax:850-430-4123
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL68781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice