Provider Demographics
NPI:1598871600
Name:DULAC, JEROME DERMOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:DERMOTT
Last Name:DULAC
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:6550 YORK AVE SO
Mailing Address - Street 2:SUITE 202
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2333
Mailing Address - Country:US
Mailing Address - Phone:952-925-2176
Mailing Address - Fax:952-925-2382
Practice Address - Street 1:6550 YORK AVE SO
Practice Address - Street 2:SUITE 202
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2333
Practice Address - Country:US
Practice Address - Phone:952-925-2176
Practice Address - Fax:952-925-2382
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MND62051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice