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General NPI Number Information
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NPI Number | 1932471166
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Entity Type | Organization
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Legal Business Name | POTATOHEAD PROPERTIES LLC
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Dates
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Enumeration Date | 02/03/2012
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Last Update Date | 05/10/2012
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Provider Practice Location Address
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Address Line | 6802 SAINT AUGUSTINE RD
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City | JACKSONVILLE
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State | FL
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Zip | 32217-2818
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Country | US
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Telephone | 904-551-3861
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Fax |
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Provider Business Mailing Address
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Address Line | 6802 SAINT AUGUSTINE RD
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City | JACKSONVILLE
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State | FL
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Zip | 32217-2818
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Country | US
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Telephone | 904-551-3861
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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. DONALD JOHN ALEXANDER
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Credential | DDS
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Telephone | 904-551-3861
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DN014816
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License Number State | FL
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