MEDICARE: JC DENTAL, LLC

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

General Provider Information

NPI Number	:	1750006938
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JC DENTAL, LLC

Provider Business Mailing Address
First Line	:	390 JEFFERSON AVE
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32065-7717
Country	:	US
Telephone Number	:	904-272-1588
Fax Number	:

Provider Business Practice Location Address
First Line	:	390 JEFFERSON AVE
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32065-7717
Country	:	US
Telephone Number	:	904-272-1588
Fax Number	:

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	JOSHUA CHUPP
Credential	:	DMD
Telephone Number	:	904-272-1588

Provider Enumeration Date	:	10/10/2022
Last Update Date	:	11/09/2022

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