Healthcare Provider Details

I. General information

NPI: 1790880912
Provider Name (Legal Business Name): ULISES ANTONIO GUZMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 COMMERCE CENTER DR UNIT 155
JACKSONVILLE FL
32225-8802
US

IV. Provider business mailing address

10435 MIDTOWN PKWY UNIT 222
JACKSONVILLE FL
32246-7465
US

V. Phone/Fax

Practice location:
  • Phone: 904-483-3022
  • Fax:
Mailing address:
  • Phone: 904-755-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN0013659
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: