Provider Demographics
NPI:1093971905
Name:DELASSEN, JAN F
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:F
Last Name:DELASSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1344 22ND ST S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-2744
Mailing Address - Country:US
Mailing Address - Phone:727-824-8177
Mailing Address - Fax:727-551-9306
Practice Address - Street 1:1344 22ND ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-2744
Practice Address - Country:US
Practice Address - Phone:727-824-8177
Practice Address - Fax:727-551-9306
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN184691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice