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General NPI Number Information
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NPI Number | 1003287814
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Entity Type | Organization
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Legal Business Name | SOUTH JACKSONVILLE DENTAL PLLC
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Dates
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Enumeration Date | 10/20/2015
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Last Update Date | 10/20/2015
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Provider Practice Location Address
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Address Line | 8440 BLANDING BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32244
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Country | US
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Telephone | 904-525-8041
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Fax | 315-410-5531
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Provider Business Mailing Address
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Address Line | 8440 BLANDING BLVD
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City | JACKSONVILLE
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State | FL
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Zip | 32244
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Country | US
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Telephone | 904-525-8041
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Fax | 315-410-5531
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Authorized Official
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Title or Position | PROVIDER RELATIONS SPECIALIST
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Name | KIM VAN CAMP
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Credential |
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Telephone | 315-454-6000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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