Provider Demographics
NPI:1629514492
Name:DELISLE, DDS, BRIAN J (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
Last Name:DELISLE, DDS
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 1:11414 SEMINOLE BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33778-3200
Mailing Address - Country:US
Mailing Address - Phone:727-398-5829
Mailing Address - Fax:727-394-2828
Practice Address - Street 1:11414 SEMINOLE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33778-3200
Practice Address - Country:US
Practice Address - Phone:727-398-5829
Practice Address - Fax:727-394-2828
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0011245122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist