Provider Demographics
NPI:1043579972
Name:CAPELLAN, JESSICA (DMD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CAPELLAN
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 1:13088 47TH CT N
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-8129
Mailing Address - Country:US
Mailing Address - Phone:561-252-1996
Mailing Address - Fax:
Practice Address - Street 1:11258 W HILLSBOROUGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33635-9762
Practice Address - Country:US
Practice Address - Phone:813-814-4309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-12
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY92021223G0001X
FLDN 202831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program