Provider Demographics
NPI:1275072159
Name:DEPALO, JOSEPH R (DMD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:R
Last Name:DEPALO
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 1:833 UNIVERSITY BLVD APT 303
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-3072
Mailing Address - Country:US
Mailing Address - Phone:508-596-3412
Mailing Address - Fax:
Practice Address - Street 1:1708 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-6668
Practice Address - Country:US
Practice Address - Phone:561-944-6647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30025262122300000X, 1223P0221X
FLDN247131223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0274059Medicaid