Healthcare Provider Details

I. General information

NPI: 1376579367
Provider Name (Legal Business Name): KEVIN TYRONE PRINCE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1536 N JEFFERSON ST
JACKSONVILLE FL
32209-6525
US

IV. Provider business mailing address

1536 N JEFFERSON ST
JACKSONVILLE FL
32209-6525
US

V. Phone/Fax

Practice location:
  • Phone: 904-475-6230
  • Fax:
Mailing address:
  • Phone: 904-475-6230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN13274
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: