MEDICARE: BOB W. DEASON, DDS, PA

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	122300000X	Dentist	DN6332	FL

General Provider Information

NPI Number	:	1861723777
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOB W. DEASON, DDS, PA

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	:	OWNER/PRESIDENT
Name	:	DR. BOB DEASON
Credential	:	DDS
Telephone Number	:	904-724-6321

Provider Enumeration Date	:	01/18/2010
Last Update Date	:	01/18/2010

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