Healthcare Provider Details

I. General information

NPI: 1073740114
Provider Name (Legal Business Name): JASLEEN KAUR RAINA D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 3RD AVE N
JACKSONVILLE BEACH FL
32250-5602
US

IV. Provider business mailing address

10458 CAROLINA WILLOW DR
FORT MYERS FL
33913-8808
US

V. Phone/Fax

Practice location:
  • Phone: 904-246-6714
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019027948
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number19561
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: