1174662480 NPI number — DENTAL CENTER DEERWOOD

Table of content: (NPI 1174662480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174662480 NPI number — DENTAL CENTER DEERWOOD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL CENTER DEERWOOD
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:
1174662480
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7899 BAYMEADOWS WAY
Provider Second Line Business Mailing Address:
SUITE #3
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32256-7572
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-731-5200
Provider Business Mailing Address Fax Number:
904-737-2427

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7899 BAYMEADOWS WAY
Provider Second Line Business Practice Location Address:
SUITE #3
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32256-7572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-731-5200
Provider Business Practice Location Address Fax Number:
904-737-2427
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PEPIS
Authorized Official First Name:
RICK
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
OWNER DENTIST
Authorized Official Telephone Number:
904-731-5200

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  8595 , 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)

  • Identifier: 8595 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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