Healthcare Provider Details

I. General information

NPI: 1023276607
Provider Name (Legal Business Name): SOUTHSIDE DERMATOLOGY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4727 SUNBEAM RD SUITE 101
JACKSONVILLE FL
32257-6107
US

IV. Provider business mailing address

4727 SUNBEAM RD SUITE 101
JACKSONVILLE FL
32257-6107
US

V. Phone/Fax

Practice location:
  • Phone: 904-880-0622
  • Fax: 904-880-0623
Mailing address:
  • Phone: 904-880-0622
  • Fax: 904-880-0623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME16473
License Number StateFL

VIII. Authorized Official

Name: DR. MARY TRINH PENTEL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 904-880-0622