Provider Demographics
NPI:1710285739
Name:DR JAMES W. MEDLOCK D.D.S.,P.A
Entity Type:Organization
Organization Name:DR JAMES W. MEDLOCK D.D.S.,P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:MEDLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:561-439-4620
Mailing Address - Street 1:2326 S CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-7617
Mailing Address - Country:US
Mailing Address - Phone:561-439-4620
Mailing Address - Fax:561-439-6704
Practice Address - Street 1:2326 S CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-7617
Practice Address - Country:US
Practice Address - Phone:561-439-4620
Practice Address - Fax:561-439-6704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-01
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 10346122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty