Provider Demographics
NPI:1518369115
Name:JILA J.MAHAJAN, D.D.S.L.L.C
Entity Type:Organization
Organization Name:JILA J.MAHAJAN, D.D.S.L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JILA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAHAJAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-423-1377
Mailing Address - Street 1:4495 ROOSEVELT BLVD STE 111
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-3382
Mailing Address - Country:US
Mailing Address - Phone:904-423-1377
Mailing Address - Fax:
Practice Address - Street 1:4495 ROOSEVELT BLVD STE 111
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-3382
Practice Address - Country:US
Practice Address - Phone:904-423-1377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIDS FIRST DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN139191223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty