Provider Demographics
NPI:1184468357
Name:JAN, BASIL
Entity type:Individual
Prefix:
First Name:BASIL
Middle Name:
Last Name:JAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7170 SW 22ND ST
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33317-7122
Mailing Address - Country:US
Mailing Address - Phone:904-312-0960
Mailing Address - Fax:
Practice Address - Street 1:5491 DOLPHIN POINT BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-3221
Practice Address - Country:US
Practice Address - Phone:904-312-0960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-22
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN28716122300000X
FL287161223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty