Healthcare Provider Details

I. General information

NPI: 1124450796
Provider Name (Legal Business Name): NATHAN MATTHEW HARPER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2013
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

472 JACKSONVILLE DR
JACKSONVILLE BEACH FL
32250-3812
US

IV. Provider business mailing address

472 JACKSONVILLE DR
JACKSONVILLE BEACH FL
32250-3812
US

V. Phone/Fax

Practice location:
  • Phone: 904-246-6545
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401414105
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDEN.00204141
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: