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General NPI Number Information
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NPI Number | 1902967177
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Entity Type | Individual
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Provider Name | MATTHEW JACKSON HENRY DDS
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Gender | Male
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Dates
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Enumeration Date | 12/12/2006
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Last Update Date | 08/15/2022
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Provider Practice Location Address
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Address Line | 6223 SAUTERNE DR
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City | JACKSONVILLE
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State | FL
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Zip | 32210-7728
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Country | US
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Telephone | 49-771-0568
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Fax |
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Provider Business Mailing Address
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Address Line | 13624 MARSH HARBOR DR N
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City | JACKSONVILLE
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State | FL
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Zip | 32225-2641
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Country | US
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Telephone | 305-336-0554
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 16175
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License Number State | FL
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