Provider Demographics
NPI:1275238305
Name:JAX BEACHES DENTAL CARE PLLC
Entity Type:Organization
Organization Name:JAX BEACHES DENTAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:HUCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-247-0111
Mailing Address - Street 1:802 3RD STREET
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32266
Mailing Address - Country:US
Mailing Address - Phone:904-247-0111
Mailing Address - Fax:904-247-3320
Practice Address - Street 1:802 3RD STREET
Practice Address - Street 2:
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266
Practice Address - Country:US
Practice Address - Phone:904-247-0111
Practice Address - Fax:904-247-3320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty