=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154096097
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEREMIAH D. PATRICK, D.M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2021
-----------------------------------------------------
Last Update Date | 02/02/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 PELHAM RD
-----------------------------------------------------
City | FORT WALTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32547-3604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-808-3636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 207 PELHAM RD
-----------------------------------------------------
City | FORT WALTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32547-3604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-808-3636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. JEREMIAH DANIEL PATRICK
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 850-808-3636
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------