Provider Demographics
NPI:1710023551
Name:GIRARDEAU, OTIS E (DDS)
Entity Type:Individual
Prefix:DR
First Name:OTIS
Middle Name:E
Last Name:GIRARDEAU
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 1:3505 SOUTHSIDE BLVD
Mailing Address - Street 2:STE.5
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4686
Mailing Address - Country:US
Mailing Address - Phone:904-564-1888
Mailing Address - Fax:904-564-1628
Practice Address - Street 1:3505 SOUTHSIDE BLVD
Practice Address - Street 2:STE.5
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4686
Practice Address - Country:US
Practice Address - Phone:904-564-1888
Practice Address - Fax:904-564-1628
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL134531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice