Provider Demographics
NPI:1619586146
Name:VALDEZ, JEAN CARLO
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:CARLO
Last Name:VALDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 TECHNOLOGY PARK STE 101
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-7122
Mailing Address - Country:US
Mailing Address - Phone:407-543-8509
Mailing Address - Fax:
Practice Address - Street 1:2045 GULF TO BAY BLVD STE B
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-3752
Practice Address - Country:US
Practice Address - Phone:727-474-0211
Practice Address - Fax:727-265-3386
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN250291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice