Provider Demographics
NPI:1053690453
Name:INGALLS, JEFFREY BROUGHTON (DMD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:BROUGHTON
Last Name:INGALLS
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 1:168 14TH ST SW STE B
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-6103
Mailing Address - Country:US
Mailing Address - Phone:727-585-5494
Mailing Address - Fax:
Practice Address - Street 1:168 14TH ST SW STE B
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-6103
Practice Address - Country:US
Practice Address - Phone:727-585-5494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0142741223S0112X
FLDN276591223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty