Healthcare Provider Details

I. General information

NPI: 1568852010
Provider Name (Legal Business Name): ECCELLA SMILES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2015
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 MARSH LANDING PKWY SUITE 104
JACKSONVILLE BEACH FL
32250-2493
US

IV. Provider business mailing address

1400 MARSH LANDING PKWY SUITE 104
JACKSONVILLE BEACH FL
32250-2493
US

V. Phone/Fax

Practice location:
  • Phone: 904-834-3737
  • Fax:
Mailing address:
  • Phone: 904-834-3737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN14961
License Number StateFL

VIII. Authorized Official

Name: DR. WILLIAM SCOTT WAGNER
Title or Position: OWNER
Credential: DMD, PA
Phone: 904-834-3737