Provider Demographics
NPI:1598981227
Name:EDDERAI, JEAN JAQUES (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:JAQUES
Last Name:EDDERAI
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 1:17101 NE 19TH AVE
Mailing Address - Street 2:SUITE#104
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-3159
Mailing Address - Country:US
Mailing Address - Phone:305-947-7999
Mailing Address - Fax:305-949-2913
Practice Address - Street 1:17101 NE 19TH AVE
Practice Address - Street 2:SUITE#104
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-3159
Practice Address - Country:US
Practice Address - Phone:305-947-7999
Practice Address - Fax:305-949-2913
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN12836122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN12836OtherDENTAL LICENSE NUMBER
FLBJ2962125OtherDEA NUMBER