Provider Demographics
NPI:1568915387
Name:JACKSONVILLE DENTAL SPECIALISTS
Entity Type:Organization
Organization Name:JACKSONVILLE DENTAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CUEVAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-683-4781
Mailing Address - Street 1:11512 LAKE MEAD AVE
Mailing Address - Street 2:STE. 532
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9680
Mailing Address - Country:US
Mailing Address - Phone:904-460-4201
Mailing Address - Fax:904-683-3914
Practice Address - Street 1:11512 LAKE MEAD AVE
Practice Address - Street 2:STE. 532
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9680
Practice Address - Country:US
Practice Address - Phone:904-460-4201
Practice Address - Fax:904-683-3914
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSONVILLE DENTAL SPECIALISTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN166481223P0300X
FLDN182801223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty