Healthcare Provider Details

I. General information

NPI: 1376636506
Provider Name (Legal Business Name): GEORGE DANIEL SELLOCK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 09/06/2021
Certification Date: 09/06/2021
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: 850-291-3733
  • Fax:
Mailing address:
  • Phone: 850-291-3733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDS027781L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: