MEDICARE: ADVANCED DENTAL CARE OF JACKSONVILLE 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

General Provider Information

NPI Number	:	1093849895
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED DENTAL CARE OF JACKSONVILLE PA

Provider Business Mailing Address
First Line	:	4540 SOUTHSIDE BLVD
Second Line	:	1001
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-5492
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4540 SOUTHSIDE BLVD
Second Line	:	1001
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-5492
Country	:	US
Telephone Number	:	904-725-4433
Fax Number	:

Authorized Official
Title or Position	:	INSURANCE DIRECTOR
Name	:	MIKE COLE
Credential	:
Telephone Number	:	727-726-1611

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	05/17/2010

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Directions to “ADVANCED DENTAL CARE OF JACKSONVILLE PA ” Practice Location

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