Provider Demographics
NPI:1740614775
Name:SURFSIDE DENTAL CENTER, PA.
Entity Type:Organization
Organization Name:SURFSIDE DENTAL CENTER, PA.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:L
Authorized Official - Last Name:LESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-998-7000
Mailing Address - Street 1:3545-1 ST. JOHNS BLUFF RD. S.
Mailing Address - Street 2:SUITE 352
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224
Mailing Address - Country:US
Mailing Address - Phone:904-998-7000
Mailing Address - Fax:904-998-7702
Practice Address - Street 1:630-7 ATLANTIC BLVD.
Practice Address - Street 2:
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266
Practice Address - Country:US
Practice Address - Phone:904-247-2626
Practice Address - Fax:904-247-2291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-27
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15716305R00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service