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General NPI Number Information
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NPI Number | 1265133185
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Entity Type | Organization
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Legal Business Name | FL SOUTHERN DENTAL PA
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Dates
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Enumeration Date | 03/16/2023
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Last Update Date | 03/16/2023
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Provider Practice Location Address
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Address Line | 100 WHETSTONE PL STE 308
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-5775
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Country | US
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Telephone | 904-810-2345
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Fax |
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Provider Business Mailing Address
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Address Line | 5830 GRANITE PKWY STE 780
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City | PLANO
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State | TX
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Zip | 75024-6775
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Country | US
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Telephone | 469-596-6011
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Fax |
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Authorized Official
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Title or Position | VP, REVENUE CYCLE
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Name | CHRISTINE NELSON
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Credential |
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Telephone | 469-596-6011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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