Provider Demographics
NPI:1891210662
Name:CANOPY OAK DENTAL, P.A.
Entity Type:Organization
Organization Name:CANOPY OAK DENTAL, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-998-7000
Mailing Address - Street 1:3545 SAINT JOHNS BLUFF RD S # 352
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-2682
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8075 SW HIGHWAY 200 STE 114-115
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34481-7823
Practice Address - Country:US
Practice Address - Phone:352-237-3008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-14
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental