Provider Demographics
NPI:1720436157
Name:BLUE SKY DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:BLUE SKY DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONAS
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-229-5794
Mailing Address - Street 1:14866 OLD ST. AUGUSTINE RD
Mailing Address - Street 2:SUITE 111 AND 112
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32288
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14866 OLD ST. AUGUSTINE RD
Practice Address - Street 2:SUITE 111 AND 112
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32288
Practice Address - Country:US
Practice Address - Phone:904-229-5794
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21709122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty