Provider Demographics
NPI:1669568861
Name:DEVILLIERS, PATRICIA (DDS)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:DEVILLIERS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14100 58TH STREET NORTH
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1344 22ND ST S
Practice Address - Street 2:
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-8757
Practice Address - Country:US
Practice Address - Phone:205-790-5866
Practice Address - Fax:727-824-8165
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL55301223P0106X, 207ZP0101X
FLDN21483207ZP0101X, 1223G0001X, 1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00373688OtherRAILROAD MEDICARE
AL051537044OtherBCBS
AL009939299Medicaid
AL051537045OtherBCBS
P00373688OtherRAILROAD MEDICARE
AL051537040OtherBCBS
051537040Medicare PIN