Healthcare Provider Details

I. General information

NPI: 1710285739
Provider Name (Legal Business Name): DR JAMES W. MEDLOCK D.D.S.,P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2011
Last Update Date: 03/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2326 S CONGRESS AVE
WEST PALM BEACH FL
33406-7617
US

IV. Provider business mailing address

2326 S CONGRESS AVE
WEST PALM BEACH FL
33406-7617
US

V. Phone/Fax

Practice location:
  • Phone: 561-439-4620
  • Fax: 561-439-6704
Mailing address:
  • Phone: 561-439-4620
  • Fax: 561-439-6704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN 10346
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES W MEDLOCK
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 561-439-4620