Provider Demographics
NPI:1043792534
Name:ATLANTIC DENTISTRY PA
Entity Type:Organization
Organization Name:ATLANTIC DENTISTRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BASTOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-647-1800
Mailing Address - Street 1:13474 ATLANTIC BLVD STE 109
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-0100
Mailing Address - Country:US
Mailing Address - Phone:904-647-1800
Mailing Address - Fax:904-647-1802
Practice Address - Street 1:13474 ATLANTIC BLVD STE 109
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-0100
Practice Address - Country:US
Practice Address - Phone:904-647-1800
Practice Address - Fax:904-647-1802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty