Healthcare Provider Details

I. General information

NPI: 1356253199
Provider Name (Legal Business Name): ORAL AND MAXILLOFACIAL SURGERY OF JACKSONVILLE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 JAIDEV ROAD BLDG 10, SUITE101
ST. JOHNS FL
32259-1140
US

IV. Provider business mailing address

95 JAIDEV ROAD BLDG 10, SUITE101
ST. JOHNS FL
32259-1140
US

V. Phone/Fax

Practice location:
  • Phone: 904-820-8956
  • Fax: 904-820-8957
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: VINCENT PERCIACCANTE
Title or Position: OWNER
Credential:
Phone: 904-820-8956