MEDICARE: DR. BOB W DEASON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN 6332	FL

General Provider Information

NPI Number	:	1548388135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BOB W DEASON DDS

Provider Business Mailing Address
First Line	:	765 MILL CREEK RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32211-6432
Country	:	US
Telephone Number	:	904-724-6321
Fax Number	:	904-721-6151

Provider Business Practice Location Address
First Line	:	765 MILL CREEK RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32211-6432
Country	:	US
Telephone Number	:	904-724-6321
Fax Number	:	904-721-6151

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	09/24/2008

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