Provider Demographics
NPI:1558378380
Name:SPAGNOLI, JAN L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:L
Last Name:SPAGNOLI
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 1:55 N. CARPENTER ROAD
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796
Mailing Address - Country:US
Mailing Address - Phone:321-269-3802
Mailing Address - Fax:321-269-0920
Practice Address - Street 1:55 N CARPENTER ROAD
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796
Practice Address - Country:US
Practice Address - Phone:321-269-3802
Practice Address - Fax:321-269-0920
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN101661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL450792OtherUNITED CONCORDIA
FL60536OtherBCBS OF FLORIDA