MEDICARE: POTATOHEAD PROPERTIES 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	DN014816	FL

General Provider Information

NPI Number	:	1932471166
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POTATOHEAD PROPERTIES LLC

Provider Business Mailing Address
First Line	:	6802 SAINT AUGUSTINE RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-2818
Country	:	US
Telephone Number	:	904-551-3861
Fax Number	:

Provider Business Practice Location Address
First Line	:	6802 SAINT AUGUSTINE RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-2818
Country	:	US
Telephone Number	:	904-551-3861
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DONALD JOHN ALEXANDER
Credential	:	DDS
Telephone Number	:	904-551-3861

Provider Enumeration Date	:	02/03/2012
Last Update Date	:	05/10/2012

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Directions to “POTATOHEAD PROPERTIES LLC ” Practice Location

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