Healthcare Provider Details

I. General information

NPI: 1598062978
Provider Name (Legal Business Name): MITCHELL R LEVINE DMD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2011
Last Update Date: 04/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 CARDINAL POINT DR
JACKSONVILLE FL
32257-5581
US

IV. Provider business mailing address

3600 CARDINAL POINT DR
JACKSONVILLE FL
32257-5581
US

V. Phone/Fax

Practice location:
  • Phone: 904-737-4626
  • Fax: 904-737-2126
Mailing address:
  • Phone: 904-737-4626
  • Fax: 904-737-2126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN10789
License Number StateFL

VIII. Authorized Official

Name: DR. MITCHELL LEVINE
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 904-737-4626