Healthcare Provider Details

I. General information

NPI: 1568513760
Provider Name (Legal Business Name): DR. KHALIL J ORSBORN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2262 DUNN AVE STE 4 SUITE #4
JACKSONVILLE FL
32218-4720
US

IV. Provider business mailing address

1449 LEGION DR
COLUMBIA SC
29229-9561
US

V. Phone/Fax

Practice location:
  • Phone: 904-745-4555
  • Fax:
Mailing address:
  • Phone: 803-699-8196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN17320
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: