Provider Demographics
NPI:1861723777
Name:BOB W. DEASON, DDS, PA
Entity type:Organization
Organization Name:BOB W. DEASON, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:DEASON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-724-6321
Mailing Address - Street 1:765 MILL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-6432
Mailing Address - Country:US
Mailing Address - Phone:904-724-6321
Mailing Address - Fax:904-721-6151
Practice Address - Street 1:765 MILL CREEK RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-6432
Practice Address - Country:US
Practice Address - Phone:904-724-6321
Practice Address - Fax:904-721-6151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-18
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN6332122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty