Healthcare Provider Details

I. General information

NPI: 1184047888
Provider Name (Legal Business Name): RODEFFER, GARNER, MINOR AND MOKRIS ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 04/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2363 DUNN AVENUE
JACKSONVILLE FL
32218
US

IV. Provider business mailing address

2363 DUNN AVENUE
JACKSONVILLE FL
32218
US

V. Phone/Fax

Practice location:
  • Phone: 904-751-6030
  • Fax:
Mailing address:
  • Phone: 904-751-6030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN9611
License Number StateFL

VIII. Authorized Official

Name: DR. DAVID TOD GARNER
Title or Position: PRESIDENT
Credential: DDS
Phone: 904-751-6030