Provider Demographics
NPI:1659855781
Name:GENTLE DENTISTS BEACHES, LLC
Entity Type:Organization
Organization Name:GENTLE DENTISTS BEACHES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHESSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-716-5888
Mailing Address - Street 1:PO BOX 19675
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-9675
Mailing Address - Country:US
Mailing Address - Phone:904-731-1919
Mailing Address - Fax:904-996-0018
Practice Address - Street 1:3316 3RD ST S STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6090
Practice Address - Country:US
Practice Address - Phone:904-731-1919
Practice Address - Fax:904-996-0018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherDENTAL