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General NPI Number Information
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NPI Number | 1073024006
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Entity Type | Organization
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Legal Business Name | JACKSONVILLE FAMILY DENTISTRY AT SOUTHSIDE, INC
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Dates
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Enumeration Date | 10/17/2017
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Last Update Date | 10/17/2017
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Provider Practice Location Address
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Address Line | 8101 SOUTHSIDE BLVD STE 8
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City | JACKSONVILLE
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State | FL
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Zip | 32256-8005
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Country | US
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Telephone | 904-641-2655
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Fax |
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Provider Business Mailing Address
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Address Line | 100 FAIRWAY PARK BLVD UNIT 512
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City | PONTE VEDRA BEACH
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State | FL
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Zip | 32082-2667
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Country | US
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Telephone | 904-210-5348
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BRYAN KEITH BLANKENSHIP
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Credential | DDS
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Telephone | 904-210-5348
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 16941
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License Number State | FL
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