Healthcare Provider Details

I. General information

NPI: 1780813766
Provider Name (Legal Business Name): JOSEPH ROBERT MUCKENTHALER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2009
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1647 ADMIRAL TAUSSIG BLVD
NORFOLK VA
23511
US

IV. Provider business mailing address

2080 CHILD ST
JACKSONVILLE FL
32214-5005
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-8547
  • Fax:
Mailing address:
  • Phone: 904-546-7139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901020028
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2901020028
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: