Healthcare Provider Details

I. General information

NPI: 1659420115
Provider Name (Legal Business Name): FORREST ROBERT JERKINS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3360 US HWY 27 SUITE A
FRUITLAND PARK FL
34731-4141
US

IV. Provider business mailing address

3360 US HWY 27/441 SUITE A
FRUITLAND PARK FL
34731-4141
US

V. Phone/Fax

Practice location:
  • Phone: 352-728-8881
  • Fax: 352-728-2650
Mailing address:
  • Phone: 352-728-8881
  • Fax: 352-728-2650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10537
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: