Provider Demographics
NPI:1366511172
Name:DE FARIAS, DEBORA G (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:DEBORA
Middle Name:G
Last Name:DE FARIAS
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11475 HALETHORPE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1313
Mailing Address - Country:US
Mailing Address - Phone:904-288-9503
Mailing Address - Fax:
Practice Address - Street 1:7740 POINT MEADOWS DR
Practice Address - Street 2:SUITE 4
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9179
Practice Address - Country:US
Practice Address - Phone:904-645-6457
Practice Address - Fax:904-645-6459
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL170991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice