Provider Demographics
NPI:1780098723
Name:BELLEBAUM, ANDREW (DMD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:BELLEBAUM
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 1:554 KEILY STREET BUREAU OF MED AND SUR
Mailing Address - Street 2:CENTRALIZED CREDENTIALS AND PRIVI PRIVILEGEING
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32312
Mailing Address - Country:US
Mailing Address - Phone:757-953-8609
Mailing Address - Fax:
Practice Address - Street 1:554 KEILY STREET BUREAU OF MED AND SUR
Practice Address - Street 2:CENTRALIZED CREDENTIALS AND PRIVILEGEING
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32312
Practice Address - Country:US
Practice Address - Phone:757-953-8609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8380122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist