MEDICARE: SAN JOSE FAMILY DENISTRY

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	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1407867237	OTHER	FL	NPI

General Provider Information

NPI Number	:	1942612502
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN JOSE FAMILY DENISTRY

Provider Business Mailing Address
First Line	:	9310 OLD KINGS RD S STE 601
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-6178
Country	:	US
Telephone Number	:	904-737-8081
Fax Number	:	904-737-3343

Provider Business Practice Location Address
First Line	:	9310 OLD KINGS RD S STE 601
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-6178
Country	:	US
Telephone Number	:	904-737-8081
Fax Number	:	904-737-3343

Authorized Official
Title or Position	:	FRONT OFFICE
Name	:	MRS. SHONDA ALLEMAND
Credential	:
Telephone Number	:	904-737-8081

Provider Enumeration Date	:	05/29/2014
Last Update Date	:	05/29/2014

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Directions to “SAN JOSE FAMILY DENISTRY ” Practice Location

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