Provider Demographics
NPI:1386531010
Name:CEBALLOS, JORGE ENRIQUE I (DDS)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:ENRIQUE
Last Name:CEBALLOS
Suffix:I
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 ORCHID GLADES LN UNIT 3
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-5386
Mailing Address - Country:US
Mailing Address - Phone:712-292-1862
Mailing Address - Fax:
Practice Address - Street 1:4705 26TH ST W STE B
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-1717
Practice Address - Country:US
Practice Address - Phone:941-220-0307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-24
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN305821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice