Provider Demographics
NPI:1275589111
Name:AMERICAN DENTAL CARE OF JACKSONVILLE, INC.
Entity Type:Organization
Organization Name:AMERICAN DENTAL CARE OF JACKSONVILLE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-272-9440
Mailing Address - Street 1:38 BLANDING BLVD
Mailing Address - Street 2:A
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2228
Mailing Address - Country:US
Mailing Address - Phone:904-272-9440
Mailing Address - Fax:904-272-0720
Practice Address - Street 1:38 BLANDING BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-2228
Practice Address - Country:US
Practice Address - Phone:904-272-9440
Practice Address - Fax:904-272-0720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN62561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty