=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720493612
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY MARGULIS DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2014
-----------------------------------------------------
Last Update Date | 10/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9119 MERRILL RD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-744-7202
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 131 SOUTHERN OAK DR
-----------------------------------------------------
City | PONTE VEDRA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32081-8364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-567-1555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN18407
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------