=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588788434
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J. WAYNE DELUCIA D.D.S., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14185 BEACH BLVD STE 2
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-1574
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-223-9999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14185 BEACH BLVD STE 2
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-1574
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-223-9999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOSEPH WAYNE DELUCIA
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 904-223-9999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC0050X
-----------------------------------------------------
Taxonomy Name | Critical Access Hospital Clinic/Center
-----------------------------------------------------
License Number | DN7365
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------