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General NPI Number Information
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NPI Number | 1699432468
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Entity Type | Organization
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Legal Business Name | ORTHO 99 PLUS 1 BARTRAM PARK LLC
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Dates
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Enumeration Date | 11/29/2021
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Last Update Date | 06/08/2022
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Provider Practice Location Address
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Address Line | 13920 OLD SAINT AUGUSTINE RD STE 103
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City | JACKSONVILLE
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State | FL
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Zip | 32258-5562
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Country | US
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Telephone | 904-640-8599
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Fax |
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Provider Business Mailing Address
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Address Line | 7410 MERRILL RD STE 2
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City | JACKSONVILLE
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State | FL
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Zip | 32277-6547
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Country | US
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Telephone | 904-619-7140
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Fax |
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Authorized Official
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Title or Position | OWNER/ORTHODONTIST
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Name | JUSTIN MCDANIEL
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Credential | DMD
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Telephone | 904-640-8599
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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