Provider Demographics
NPI:1821149493
Name:DELASANTA, DEAN (DDS)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:
Last Name:DELASANTA
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 1:1431 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3441
Mailing Address - Country:US
Mailing Address - Phone:920-458-4142
Mailing Address - Fax:
Practice Address - Street 1:1431 N 8TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3441
Practice Address - Country:US
Practice Address - Phone:920-458-4142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33769500Medicaid