MEDICARE: BRUSHES AND BRACKETS DENTAL STUDIO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023772704
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRUSHES AND BRACKETS DENTAL STUDIO

Provider Business Mailing Address
First Line	:	2255 DUNN AVE STE 700
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-4742
Country	:	US
Telephone Number	:	904-751-5126
Fax Number	:	904-751-5146

Provider Business Practice Location Address
First Line	:	2255 DUNN AVE STE 700
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-4742
Country	:	US
Telephone Number	:	904-751-5126
Fax Number	:	904-751-5146

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TANYA WALL
Credential	:	DDS
Telephone Number	:	904-751-5126

Provider Enumeration Date	:	10/28/2021
Last Update Date	:	10/28/2021

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Directions to “BRUSHES AND BRACKETS DENTAL STUDIO ” Practice Location

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