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General NPI Number Information
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NPI Number | 1033465349
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Entity Type | Organization
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Legal Business Name | REGENCY SQUARE MALL DENTAL
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Dates
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Enumeration Date | 07/24/2012
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Last Update Date | 12/03/2014
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Provider Practice Location Address
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Address Line | 9501 ARLINGTON EXPY STE#0345
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City | JACKSONVILLE
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State | FL
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Zip | 32225-8200
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Country | US
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Telephone | 904-727-6055
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Fax |
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Provider Business Mailing Address
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Address Line | 9501 ARLINGTON EXPY STE#0345
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City | JACKSONVILLE
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State | FL
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Zip | 32225-8200
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Country | US
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Telephone | 904-727-6055
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. ROSTISLAV KRASNOV
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Credential | DDS
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Telephone | 904-727-6055
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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 | DN16377
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License Number State | FL
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