Provider Demographics
NPI:1003287814
Name:SOUTH JACKSONVILLE DENTAL PLLC
Entity Type:Organization
Organization Name:SOUTH JACKSONVILLE DENTAL PLLC
Other - Org Name:ASPEN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER RELATIONS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN CAMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-454-6000
Mailing Address - Street 1:8440 BLANDING BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244
Mailing Address - Country:US
Mailing Address - Phone:904-525-8041
Mailing Address - Fax:315-410-5531
Practice Address - Street 1:8440 BLANDING BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244
Practice Address - Country:US
Practice Address - Phone:904-525-8041
Practice Address - Fax:315-410-5531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty