Provider Demographics
NPI:1194873224
Name:DELLAPORTA, JOHN MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:DELLAPORTA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 PROFESSIONAL DR
Mailing Address - Street 2:SUITE 107
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-6276
Mailing Address - Country:US
Mailing Address - Phone:904-280-4151
Mailing Address - Fax:904-280-0172
Practice Address - Street 1:135 PROFESSIONAL DR
Practice Address - Street 2:SUITE 107
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-6276
Practice Address - Country:US
Practice Address - Phone:904-280-4151
Practice Address - Fax:904-280-0172
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00123071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice