Provider Demographics
NPI:1043368251
Name:JETHWA, DEEPALI NILESH (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEEPALI
Middle Name:NILESH
Last Name:JETHWA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20904 AVENEL RUN
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-1222
Mailing Address - Country:US
Mailing Address - Phone:561-479-2817
Mailing Address - Fax:
Practice Address - Street 1:1209 W BROWARD BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1640
Practice Address - Country:US
Practice Address - Phone:954-763-3358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN163681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice