=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518556679
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERSIDE DENTAL OF DUNNELLON, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2021
-----------------------------------------------------
Last Update Date | 01/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11352 N WILLIAMS ST STE 505
-----------------------------------------------------
City | DUNNELLON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34432-8312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-533-5030
-----------------------------------------------------
Fax | 904-998-7702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2801 SAINT JOHNS BLUFF RD S STE 201
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32246-3862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-998-7000
-----------------------------------------------------
Fax | 904-998-7702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | DR. NICHOLAS A. NARDUCCI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-998-7000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------