Provider Demographics
NPI:1548388135
Name:DEASON, BOB W (DDS)
Entity Type:Individual
Prefix:DR
First Name:BOB
Middle Name:W
Last Name:DEASON
Suffix:
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 1:765 MILL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-6432
Mailing Address - Country:US
Mailing Address - Phone:904-724-6321
Mailing Address - Fax:904-721-6151
Practice Address - Street 1:765 MILL CREEK RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-6432
Practice Address - Country:US
Practice Address - Phone:904-724-6321
Practice Address - Fax:904-721-6151
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 63321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice