Healthcare Provider Details

I. General information

NPI: 1659752061
Provider Name (Legal Business Name): JYOTI KANSAL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 06/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 PROVIDENCE BLVD STE B
DELTONA FL
32725-7362
US

IV. Provider business mailing address

11116 SOLSTICE LOOP
SANFORD FL
32771-0075
US

V. Phone/Fax

Practice location:
  • Phone: 386-574-8388
  • Fax:
Mailing address:
  • Phone: 909-908-1892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN21360
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: