MEDICARE: PROFESSIONAL DENTAL ALLIANCE OF JACKSONVILLE SAN JOSE, PLLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1578113254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL DENTAL ALLIANCE OF JACKSONVILLE SAN JOSE, PLLC

Provider Business Mailing Address
First Line	:	11 S MILL ST STE 200
Second Line	:
City	:	NEW CASTLE
State	:	PA
Zip	:	16101-3680
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9776 SAN JOSE BLVD STE 7
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-5464
Country	:	US
Telephone Number	:	904-201-3565
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	LAUREN HOWARD
Credential	:	MA
Telephone Number	:	757-576-5479

Provider Enumeration Date	:	09/16/2019
Last Update Date	:	09/16/2019

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