Healthcare Provider Details

I. General information

NPI: 1740614775
Provider Name (Legal Business Name): SURFSIDE DENTAL CENTER, PA.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2013
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630-7 ATLANTIC BLVD.
NEPTUNE BEACH FL
32266
US

IV. Provider business mailing address

3545-1 ST. JOHNS BLUFF RD. S. SUITE 352
JACKSONVILLE FL
32224
US

V. Phone/Fax

Practice location:
  • Phone: 904-247-2626
  • Fax: 904-247-2291
Mailing address:
  • Phone: 904-998-7000
  • Fax: 904-998-7702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberDN15716
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberDN15716
License Number StateFL

VIII. Authorized Official

Name: CRYSTAL L LESS
Title or Position: VP OF OPERATIONS
Credential:
Phone: 904-998-7000