Healthcare Provider Details

I. General information

NPI: 1720487135
Provider Name (Legal Business Name): NODESH SHYAMSUNDER B.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 03/17/2018
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

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN20907
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: