Healthcare Provider Details

I. General information

NPI: 1073760658
Provider Name (Legal Business Name): JOSHUA LEO GOLDKNOPF D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 3RD ST N
JACKSONVILLE BEACH FL
32250-7427
US

IV. Provider business mailing address

1915 3RD ST N
JACKSONVILLE BEACH FL
32250-7427
US

V. Phone/Fax

Practice location:
  • Phone: 904-249-0037
  • Fax: 904-247-0140
Mailing address:
  • Phone: 904-249-0037
  • Fax: 904-247-0140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN18174
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: