Provider Demographics
NPI:1518556679
Name:RIVERSIDE DENTAL OF DUNNELLON, PA
Entity Type:Organization
Organization Name:RIVERSIDE DENTAL OF DUNNELLON, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:NARDUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-998-7000
Mailing Address - Street 1:2801 SAINT JOHNS BLUFF RD S STE 201
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-3862
Mailing Address - Country:US
Mailing Address - Phone:904-998-7000
Mailing Address - Fax:904-998-7702
Practice Address - Street 1:11352 N WILLIAMS ST STE 505
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34432-8312
Practice Address - Country:US
Practice Address - Phone:352-533-5030
Practice Address - Fax:904-998-7702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-13
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental