MEDICARE: ECCELLA SMILES 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	1223G0001X	General Practice Dentistry	DN14961	FL

General Provider Information

NPI Number	:	1568852010
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ECCELLA SMILES PA

Provider Business Mailing Address
First Line	:	1400 MARSH LANDING PKWY
Second Line	:	SUITE 104
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-2493
Country	:	US
Telephone Number	:	904-834-3737
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 MARSH LANDING PKWY
Second Line	:	SUITE 104
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-2493
Country	:	US
Telephone Number	:	904-834-3737
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WILLIAM SCOTT WAGNER
Credential	:	DMD, PA
Telephone Number	:	904-834-3737

Provider Enumeration Date	:	02/04/2015
Last Update Date	:	02/04/2015

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Directions to “ECCELLA SMILES PA ” Practice Location

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