=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982092326
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERIODONTAL SPECIALISTS OF NORTH FLORIDA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2015
-----------------------------------------------------
Last Update Date | 01/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1409 KINGSLEY AVE SUITE 9A
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-4537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-278-1175
-----------------------------------------------------
Fax | 904-278-1176
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1409 KINGSLEY AVE SUITE 9A
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-4537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-278-1175
-----------------------------------------------------
Fax | 904-278-1176
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANGELINE A KUZNIA
-----------------------------------------------------
Credential | D.M.D, M.S.
-----------------------------------------------------
Telephone | 904-278-1175
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN17936
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN15267
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------