Provider Demographics
NPI:1588633515
Name:DELISI, DONALD CHARLES JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:CHARLES
Last Name:DELISI
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:DONALD
Other - Middle Name:CHARLES
Other - Last Name:DELISI
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:2584 NE KEVOS POND DR
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-6320
Mailing Address - Country:US
Mailing Address - Phone:360-649-7625
Mailing Address - Fax:
Practice Address - Street 1:19785 VILLAGE OFFICE CT STE 102
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1944
Practice Address - Country:US
Practice Address - Phone:541-383-6515
Practice Address - Fax:541-383-1488
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000101341223S0112X
ORD78891223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery