Provider Demographics
NPI:1750877346
Name:DHALL, JAGDEEP (DMD)
Entity type:Individual
Prefix:DR
First Name:JAGDEEP
Middle Name:
Last Name:DHALL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 WAYMONT CT
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-6745
Mailing Address - Country:US
Mailing Address - Phone:724-840-5066
Mailing Address - Fax:
Practice Address - Street 1:430 WAYMONT CT
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-6745
Practice Address - Country:US
Practice Address - Phone:724-840-5066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN23561122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist