Provider Demographics
NPI:1942698204
Name:BEAN SPROUT INC
Entity Type:Organization
Organization Name:BEAN SPROUT INC
Other - Org Name:BEAN TREE PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-372-3260
Mailing Address - Street 1:2008 RIVERSIDE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4443
Mailing Address - Country:US
Mailing Address - Phone:904-372-3260
Mailing Address - Fax:904-385-3704
Practice Address - Street 1:2008 RIVERSIDE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4443
Practice Address - Country:US
Practice Address - Phone:904-372-3260
Practice Address - Fax:904-385-3704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17658261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental