Healthcare Provider Details

I. General information

NPI: 1043668593
Provider Name (Legal Business Name): EMAN OTHMAN BDS, MS, CAGS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2016
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 UNIVERSITY BLVD N
JACKSONVILLE FL
32211-3321
US

IV. Provider business mailing address

2800 UNIVERSITY BLVD N
JACKSONVILLE FL
32211-3321
US

V. Phone/Fax

Practice location:
  • Phone: 904-256-7847
  • Fax: 904-256-7798
Mailing address:
  • Phone: 904-256-7847
  • Fax: 904-256-7798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDTP 633
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: