Provider Demographics
NPI:1831858067
Name:JACKSONVILLE TONGUE TIE LLC
Entity type:Organization
Organization Name:JACKSONVILLE TONGUE TIE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:VEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-584-9004
Mailing Address - Street 1:196 EVEREST LN STE 1
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4103
Mailing Address - Country:US
Mailing Address - Phone:904-584-9004
Mailing Address - Fax:904-347-2011
Practice Address - Street 1:196 EVEREST LN STE 1
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-4103
Practice Address - Country:US
Practice Address - Phone:904-584-9004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty