Provider Demographics
NPI:1033465349
Name:REGENCY SQUARE MALL DENTAL
Entity Type:Organization
Organization Name:REGENCY SQUARE MALL DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSTISLAV
Authorized Official - Middle Name:
Authorized Official - Last Name:KRASNOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-727-6055
Mailing Address - Street 1:9501 ARLINGTON EXPY
Mailing Address - Street 2:STE#0345
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-8200
Mailing Address - Country:US
Mailing Address - Phone:904-727-6055
Mailing Address - Fax:
Practice Address - Street 1:9501 ARLINGTON EXPY
Practice Address - Street 2:STE#0345
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-8200
Practice Address - Country:US
Practice Address - Phone:904-727-6055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16377122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty