Provider Demographics
NPI:1376561639
Name:PATCH, GENE R (DMD)
Entity Type:Individual
Prefix:
First Name:GENE
Middle Name:R
Last Name:PATCH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10609 OLD SAINT AUGUSTINE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-1019
Mailing Address - Country:US
Mailing Address - Phone:904-268-1331
Mailing Address - Fax:
Practice Address - Street 1:10609 OLD SAINT AUGUSTINE RD STE 3
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-1019
Practice Address - Country:US
Practice Address - Phone:904-268-1331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD89521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL60820OtherBLUE CROSS-BLUE SHIELD
FL637072OtherUNITED CONCORDIA INS
FLT96210Medicare UPIN