Healthcare Provider Details

I. General information

NPI: 1619586146
Provider Name (Legal Business Name): JEAN CARLO VALDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 GULF TO BAY BLVD STE B
CLEARWATER FL
33765-3752
US

IV. Provider business mailing address

600 TECHNOLOGY PARK STE 101
LAKE MARY FL
32746-7122
US

V. Phone/Fax

Practice location:
  • Phone: 727-474-0211
  • Fax: 727-265-3386
Mailing address:
  • Phone: 407-543-8509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN25029
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: