Provider Demographics
NPI:1699218800
Name:MANDARIN SOUTH DENTISTRY PA
Entity Type:Organization
Organization Name:MANDARIN SOUTH DENTISTRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NANJAPPA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIVASHANAKR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-268-7552
Mailing Address - Street 1:12421 SAN JOSE BLVD STE 2A
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8663
Mailing Address - Country:US
Mailing Address - Phone:904-268-7552
Mailing Address - Fax:904-268-9792
Practice Address - Street 1:12421 SAN JOSE BLVD STE 2A
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8663
Practice Address - Country:US
Practice Address - Phone:904-268-7552
Practice Address - Fax:904-268-9792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN9317122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12OtherDENTIST