Healthcare Provider Details

I. General information

NPI: 1114365970
Provider Name (Legal Business Name): AGERICO M SAYOC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13167 ATLANTIC BLVD
JACKSONVILLE FL
32225-3125
US

IV. Provider business mailing address

13167 ATLANTIC BLVD
JACKSONVILLE FL
32225-3125
US

V. Phone/Fax

Practice location:
  • Phone: 904-221-0054
  • Fax: 904-221-0049
Mailing address:
  • Phone: 904-221-0054
  • Fax: 904-221-0049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN10831
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: