Provider Demographics
NPI:1285038786
Name:MCDANIEL, JUSTIN (MSD, DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:MSD, DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7410 MERRILL RD STE 2
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-6547
Mailing Address - Country:US
Mailing Address - Phone:904-619-7140
Mailing Address - Fax:
Practice Address - Street 1:7410 MERRILL RD STE 2
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-6547
Practice Address - Country:US
Practice Address - Phone:904-619-7140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20940122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist