Provider Demographics
NPI:1073024006
Name:JACKSONVILLE FAMILY DENTISTRY AT SOUTHSIDE, INC
Entity Type:Organization
Organization Name:JACKSONVILLE FAMILY DENTISTRY AT SOUTHSIDE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:BLANKENSHIP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-210-5348
Mailing Address - Street 1:100 FAIRWAY PARK BLVD UNIT 512
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-2667
Mailing Address - Country:US
Mailing Address - Phone:904-210-5348
Mailing Address - Fax:
Practice Address - Street 1:8101 SOUTHSIDE BLVD STE 8
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-8005
Practice Address - Country:US
Practice Address - Phone:904-641-2655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16941261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental