MEDICARE: HAYA DEMETREE

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	DN24132	FL

General Provider Information

NPI Number	:	1417515966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HAYA DEMETREE

Provider Business Mailing Address
First Line	:	13720 OLD SAINT AUGUSTINE RD STE 5
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-7415
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13720 OLD SAINT AUGUSTINE RD STE 5
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-7415
Country	:	US
Telephone Number	:	904-292-1002
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2019
Last Update Date	:	05/30/2019

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Directions to “ HAYA DEMETREE ” Practice Location

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