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General NPI Number Information
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NPI Number | 1679972665
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Entity Type | Organization
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Legal Business Name | MARIETTA DENTAL GROUP
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Dates
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Enumeration Date | 08/15/2014
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Last Update Date | 01/26/2015
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Provider Practice Location Address
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Address Line | 8209 W. BEAVER ST. SUITE 100
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City | JACKSONVILLE
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State | FL
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Zip | 32220
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Country | US
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Telephone | 904-998-7000
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Fax | 904-998-7702
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Provider Business Mailing Address
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Address Line | 3545-1 ST. JOHNS BLUFF RD. S. SUITE 352
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City | JACKSONVILLE
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State | FL
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Zip | 32224
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Country | US
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Telephone | 904-998-7000
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Fax | 904-998-7702
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Authorized Official
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Title or Position | VP OF OPERATIONS
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Name | CRYSTAL L LESS
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Credential |
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Telephone | 904-998-7000
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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 | DN15716
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License Number State | FL
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