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General NPI Number Information
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NPI Number | 1184004228
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Entity Type | Individual
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Provider Name | SERGIO JULIO JACAS D.M.D
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Gender | Male
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Dates
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Enumeration Date | 06/03/2015
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Last Update Date | 06/03/2015
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Provider Practice Location Address
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Address Line | 1720 SW 47TH AVE
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City | FORT LAUDERDALE
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State | FL
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Zip | 33317-5619
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Country | US
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Telephone | 954-615-7964
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Fax |
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Provider Business Mailing Address
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Address Line | 1720 SW 47TH AVE
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City | FORT LAUDERDALE
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State | FL
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Zip | 33317-5619
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN21198
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN21198
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License Number State | FL
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