Healthcare Provider Details

I. General information

NPI: 1912014937
Provider Name (Legal Business Name): PEDIATRIC SMILES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2262 DUNN AVE STE 4
JACKSONVILLE FL
32218
US

IV. Provider business mailing address

PO BOX 26701
JACKSONVILLE FL
32226-6701
US

V. Phone/Fax

Practice location:
  • Phone: 904-751-5126
  • Fax: 904-751-5146
Mailing address:
  • Phone: 904-751-5126
  • Fax: 904-751-5146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN 15344
License Number StateFL

VIII. Authorized Official

Name: DR. STACI SUGGS
Title or Position: OWNER/DENTIST
Credential: D.D.S.
Phone: 904-751-5126