=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205251790
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURFSIDE DENTAL SPECIALIST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2014
-----------------------------------------------------
Last Update Date | 01/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 630 ATLANTIC BLVD SUITE 7
-----------------------------------------------------
City | NEPTUNE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32266-4000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-998-7000
-----------------------------------------------------
Fax | 904-998-7702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3545-1 ST. JOHNS BLUFF RD. S. SUITE 352
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-998-7000
-----------------------------------------------------
Fax | 904-998-7702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF OPERATIONS
-----------------------------------------------------
Name | CRYSTAL L LESS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-998-7000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------