Provider Demographics
NPI:1790024248
Name:ST. JOHNS RIVER DENTAL
Entity Type:Organization
Organization Name:ST. JOHNS RIVER DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PC
Authorized Official - Phone:386-325-5467
Mailing Address - Street 1:500 S HIGHWAY 19
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-3943
Mailing Address - Country:US
Mailing Address - Phone:386-325-5467
Mailing Address - Fax:386-325-2635
Practice Address - Street 1:500 S HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3943
Practice Address - Country:US
Practice Address - Phone:386-325-5467
Practice Address - Fax:386-325-2635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty