Provider Demographics
NPI:1265756571
Name:DENTAL SPECIALISTS OF NORTH FLORIDA LLC
Entity type:Organization
Organization Name:DENTAL SPECIALISTS OF NORTH FLORIDA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:THOUSAND
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:386-445-4242
Mailing Address - Street 1:3 CYPRESS BRANCH WAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-8409
Mailing Address - Country:US
Mailing Address - Phone:386-445-4242
Mailing Address - Fax:386-445-4247
Practice Address - Street 1:3 CYPRESS BRANCH WAY
Practice Address - Street 2:SUITE C
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-8409
Practice Address - Country:US
Practice Address - Phone:386-445-4242
Practice Address - Fax:386-445-4247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN79671223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty