Provider Demographics
NPI:1376964353
Name:SORRENTO DENTAL
Entity Type:Organization
Organization Name:SORRENTO DENTAL
Other - Org Name:JULINGTON DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:SPEIGEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-230-5537
Mailing Address - Street 1:106 JULINGTON PLAZA DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-6217
Mailing Address - Country:US
Mailing Address - Phone:904-230-5537
Mailing Address - Fax:904-230-5539
Practice Address - Street 1:106 JULINGTON PLAZA DR
Practice Address - Street 2:SUITE 6
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32259-6217
Practice Address - Country:US
Practice Address - Phone:904-230-5537
Practice Address - Fax:904-230-5539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17027261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental