=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982952487
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUPS DENTAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2012
-----------------------------------------------------
Last Update Date | 08/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1329 LANE AVE S STE 1
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32205-6111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-683-0415
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1329 LANE AVE S STE 1
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32205-6111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-738-7856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CARLOS JAVIER SANTIAGO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 904-738-7735
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 13959
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------