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General NPI Number Information
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NPI Number | 1720436157
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Entity Type | Organization
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Legal Business Name | BLUE SKY DENTAL GROUP, LLC
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Dates
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Enumeration Date | 05/26/2016
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Last Update Date | 05/26/2016
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Provider Practice Location Address
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Address Line | 14866 OLD ST. AUGUSTINE RD SUITE 111 AND 112
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City | JACKSONVILLE
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State | FL
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Zip | 32288
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Country | US
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Telephone | 904-229-5794
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Fax |
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Provider Business Mailing Address
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Address Line | 14866 OLD ST. AUGUSTINE RD SUITE 111 AND 112
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City | JACKSONVILLE
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State | FL
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Zip | 32288
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | JONAS ASHBAUGH
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Credential | DDS
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Telephone | 904-229-5794
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN21709
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License Number State | FL
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