Healthcare Provider Details

I. General information

NPI: 1841038916
Provider Name (Legal Business Name): SHAWNA DEGRANGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2024
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 12TH AVE N
JACKSONVILLE BEACH FL
32250-2834
US

IV. Provider business mailing address

1516 12TH AVE N
JACKSONVILLE BEACH FL
32250-2834
US

V. Phone/Fax

Practice location:
  • Phone: 908-581-9830
  • Fax:
Mailing address:
  • Phone: 908-581-9830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN26998
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: