MEDICARE: JACKSONVILLE DENTISTRY PLLC

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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	DN19430	OTHER	FL	STATE LICENSE
3	DN21484	OTHER	FL	STATE LICENSE

General Provider Information

NPI Number	:	1417541079
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSONVILLE DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	12058 SAN JOSE BLVD STE 102
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-8669
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12058 SAN JOSE BLVD STE 102
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-8669
Country	:	US
Telephone Number	:	904-880-3131
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PETER KELLY
Credential	:
Telephone Number	:	410-410-3031

Provider Enumeration Date	:	02/24/2021
Last Update Date	:	02/24/2021

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