Provider Demographics
NPI:1144398348
Name:LESAN, JON DOUGLAS (DDS RPH PA)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:DOUGLAS
Last Name:LESAN
Suffix:
Gender:M
Credentials:DDS RPH PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 COBIA CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6862
Mailing Address - Country:US
Mailing Address - Phone:910-347-1211
Mailing Address - Fax:910-347-0765
Practice Address - Street 1:200 PRESTON RD
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540
Practice Address - Country:US
Practice Address - Phone:910-347-1211
Practice Address - Fax:910-347-0765
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC58651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
BL4097691OtherDEA
BL4097691OtherDEA