Provider Demographics
NPI:1306015599
Name:DEGAETANO, LORI MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LORI
Middle Name:MARIE
Last Name:DEGAETANO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10801 STARKEY RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33777-1159
Mailing Address - Country:US
Mailing Address - Phone:727-398-6553
Mailing Address - Fax:727-398-6838
Practice Address - Street 1:10801 STARKEY RD
Practice Address - Street 2:SUITE 301
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33777-1159
Practice Address - Country:US
Practice Address - Phone:727-398-6553
Practice Address - Fax:727-398-6838
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0011054122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist