Healthcare Provider Details

I. General information

NPI: 1730128869
Provider Name (Legal Business Name): JIMMIE DWIGHT LASSITER JR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5285 COMMERCE ST
JAY FL
32565-1179
US

IV. Provider business mailing address

3200 COBBTOWN RD
JAY FL
32565-9206
US

V. Phone/Fax

Practice location:
  • Phone: 850-675-8545
  • Fax: 850-675-1950
Mailing address:
  • Phone: 850-675-6715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN0014325
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: