Provider Demographics
NPI:1306072863
Name:DELUCIA, MICHAEL WAYNE (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:DELUCIA
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 1:14185 BEACH BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32250-1582
Mailing Address - Country:US
Mailing Address - Phone:904-223-9999
Mailing Address - Fax:
Practice Address - Street 1:14185 BEACH BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250-1582
Practice Address - Country:US
Practice Address - Phone:904-223-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN186401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice