Healthcare Provider Details

I. General information

NPI: 1568915387
Provider Name (Legal Business Name): JACKSONVILLE DENTAL SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11512 LAKE MEAD AVE STE. 532
JACKSONVILLE FL
32256-9680
US

IV. Provider business mailing address

11512 LAKE MEAD AVE STE. 532
JACKSONVILLE FL
32256-9680
US

V. Phone/Fax

Practice location:
  • Phone: 904-460-4201
  • Fax: 904-683-3914
Mailing address:
  • Phone: 904-460-4201
  • Fax: 904-683-3914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN16648
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN18280
License Number StateFL

VIII. Authorized Official

Name: LYDIA CUEVAS
Title or Position: PRACTICE COORDINATOR
Credential:
Phone: 904-683-4781