=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982017471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AFFORDABLE DENTURES-JACKSONVILLE, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2014
-----------------------------------------------------
Last Update Date | 06/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10503 SAN JOSE BLVD SUITE 10
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32257-6295
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-262-3695
-----------------------------------------------------
Fax | 904-262-3906
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10503 SAN JOSE BLVD SUITE 10
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32257-6295
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-262-3695
-----------------------------------------------------
Fax | 904-262-3906
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. EFTHEMIOS S TELLIOS
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 904-262-3695
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN12562
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------