Provider Demographics
NPI:1952648396
Name:RIVER CITY PEDIATRIC DENTISTRY, P.A.
Entity Type:Organization
Organization Name:RIVER CITY PEDIATRIC DENTISTRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:GREMILLION
Authorized Official - Last Name:MAPLES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-880-5437
Mailing Address - Street 1:9857 OLD SAINT AUGUSTINE RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-8853
Mailing Address - Country:US
Mailing Address - Phone:904-880-5437
Mailing Address - Fax:904-880-1490
Practice Address - Street 1:9857 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:SUITE 3
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-8853
Practice Address - Country:US
Practice Address - Phone:904-880-5437
Practice Address - Fax:904-880-1490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18271261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental