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General NPI Number Information
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NPI Number | 1265402119
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Entity Type | Organization
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Legal Business Name | FIRE CREEK DENTAL
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Dates
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Enumeration Date | 01/24/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1510 WILLOW BRANCH AVE
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City | JACKSONVILLE
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State | FL
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Zip | 32205-8118
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Country | US
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Telephone | 904-387-3535
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Fax | 904-389-1208
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Provider Business Mailing Address
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Address Line | 1510 WILLOW BRANCH AVE
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City | JACKSONVILLE
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State | FL
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Zip | 32205-8118
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Country | US
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Telephone | 904-387-3535
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Fax | 904-389-1208
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Authorized Official
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Title or Position | MANAGER
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Name | BARBARA SHELLMAN
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Credential |
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Telephone | 904-387-3535
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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 | 2333
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License Number State | FL
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