=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255470936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGERICO M SAYOC DMD MSD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 06/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13167 ATLANTIC BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32225-3125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-221-0054
-----------------------------------------------------
Fax | 904-221-0049
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13167 ATLANTIC BLVD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32225-3125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-221-0054
-----------------------------------------------------
Fax | 904-221-0049
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT DENTIST
-----------------------------------------------------
Name | AGERICO M SAYOC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-221-0054
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | DN10831
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------