Provider Demographics
NPI:1295231819
Name:LARROC DENTAL
Entity Type:Organization
Organization Name:LARROC DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:CORRAL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-442-6000
Mailing Address - Street 1:7768 OZARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-5839
Mailing Address - Country:US
Mailing Address - Phone:904-442-6000
Mailing Address - Fax:904-503-1440
Practice Address - Street 1:7768 OZARK DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5839
Practice Address - Country:US
Practice Address - Phone:904-442-6000
Practice Address - Fax:904-503-1440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN170631223G0001X
FLDN27881223G0001X
FLDN144721223G0001X
FLDH23171124Q00000X
FLDH9959124Q00000X
FLDH24089124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1992831341Medicaid
FL1275513434Medicaid
FL1730600958Medicaid