Healthcare Provider Details

I. General information

NPI: 1144902719
Provider Name (Legal Business Name): ORTHO 99 PLUS 1 BEACH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14333 BEACH BLVD STE 19
JACKSONVILLE FL
32250-1587
US

IV. Provider business mailing address

14536 PLUMOSA DR
JACKSONVILLE BEACH FL
32250-2222
US

V. Phone/Fax

Practice location:
  • Phone: 904-619-7140
  • Fax:
Mailing address:
  • Phone: 352-494-2676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN MCDANIEL
Title or Position: OWNER
Credential: DMD
Phone: 352-494-2676