Provider Demographics
NPI:1275742538
Name:BRIAN J. DELISLE, DDS, PA
Entity Type:Organization
Organization Name:BRIAN J. DELISLE, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DELISLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:727-398-5829
Mailing Address - Street 1:11414 SEMINOLE BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33778-3200
Mailing Address - Country:US
Mailing Address - Phone:727-398-5829
Mailing Address - Fax:
Practice Address - Street 1:11414 SEMINOLE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33778-3200
Practice Address - Country:US
Practice Address - Phone:727-398-5829
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00112451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty