Healthcare Provider Details

I. General information

NPI: 1124182696
Provider Name (Legal Business Name): DR STUART KIMMEL DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 06/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 N THIRD STREET
JACKSONVILLE BEACH FL
32250
US

IV. Provider business mailing address

1915 N THIRD STREET
JACKSONVILLE BEACH FL
32250
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 NumberDN4620
License Number StateFL

VIII. Authorized Official

Name: DR. STUART KIMMEL
Title or Position: ORTHODONTIST
Credential: DDS
Phone: 904-249-0037