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General NPI Number Information
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NPI Number | 1811245319
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Entity Type | Organization
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Legal Business Name | CSSS HOLDINGS OF ORANGE PARK, INC
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Dates
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Enumeration Date | 08/15/2012
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Last Update Date | 08/15/2012
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Provider Practice Location Address
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Address Line | 4131 UNIVERSITY BLVD S STE 1
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City | JACKSONVILLE
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State | FL
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Zip | 32216-4346
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Country | US
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Telephone | 904-738-7856
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Fax |
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Provider Business Mailing Address
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Address Line | 4131 UNIVERSITY BLVD S STE 1
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City | JACKSONVILLE
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State | FL
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Zip | 32216-4346
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Country | US
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Telephone | 904-738-7856
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. CARLOS SANTIAGO
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Credential |
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Telephone | 904-738-7856
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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 | 13959
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License Number State | FL
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