Provider Demographics
NPI:1023772704
Name:BRUSHES AND BRACKETS DENTAL STUDIO
Entity type:Organization
Organization Name:BRUSHES AND BRACKETS DENTAL STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-751-5126
Mailing Address - Street 1:2255 DUNN AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-4742
Mailing Address - Country:US
Mailing Address - Phone:904-751-5126
Mailing Address - Fax:904-751-5146
Practice Address - Street 1:2255 DUNN AVE STE 700
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4742
Practice Address - Country:US
Practice Address - Phone:904-751-5126
Practice Address - Fax:904-751-5146
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRUSHES AND BRACKETS DENTAL STUDIO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103221100Medicaid