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General NPI Number Information
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NPI Number | 1013376219
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Entity Type | Organization
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Legal Business Name | MIDBAY DENTAL PPLC
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Dates
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Enumeration Date | 02/16/2016
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Last Update Date | 02/04/2022
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Provider Practice Location Address
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Address Line | 4579 E HIGHWAY 20 STE 210
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City | NICEVILLE
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State | FL
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Zip | 32578-9810
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Country | US
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Telephone | 850-897-4200
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Fax | 850-897-4504
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Provider Business Mailing Address
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Address Line | 4579 E HIGHWAY 20 STE 210
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City | NICEVILLE
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State | FL
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Zip | 32578-9810
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Country | US
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Telephone | 850-897-4200
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Fax | 850-897-4504
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Authorized Official
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Title or Position | OWNER
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Name | DR. JUSTINE KONANE CHASE
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Credential | DDS
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Telephone | 850-897-4200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN14797
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License Number State | FL
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