=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821404914
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED MAXILLOFACIAL SURGICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2014
-----------------------------------------------------
Last Update Date | 01/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3625 UNIVERSITY BLVD S
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-4207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-702-6111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4257 POINT LA VISTA RD W
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32207-6247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-703-2236
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JASON LEE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 904-444-1578
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DN18554
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------