1649590373 NPI number — SMILE DESIGN AT AGAPE FAMILY DENTISTRY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649590373 NPI number — SMILE DESIGN AT AGAPE FAMILY DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMILE DESIGN AT AGAPE FAMILY DENTISTRY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649590373
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8750 PERIMETER PARK BLVD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-725-4444
Provider Business Mailing Address Fax Number:
386-364-5199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7505 ARLINGTON EXPY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32211-5951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-725-4444
Provider Business Practice Location Address Fax Number:
904-724-7307
Provider Enumeration Date:
06/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GERRY
Authorized Official First Name:
CHARLOTTE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
904-725-4444

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN14223 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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