1275739237 NPI number — AMANDO DENTAL CORPORATION

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 1275739237 NPI number — AMANDO DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMANDO DENTAL CORPORATION
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:
6
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:
1275739237
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3545-1 ST. JOHNS BLUFF RD. S.
Provider Second Line Business Mailing Address:
SUITE 352
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-998-7000
Provider Business Mailing Address Fax Number:
904-998-7702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4540 SOUTHSIDE BLVD
Provider Second Line Business Practice Location Address:
SUITE 801
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-5492
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-642-2010
Provider Business Practice Location Address Fax Number:
904-642-8282
Provider Enumeration Date:
06/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LESS
Authorized Official First Name:
CRYSTAL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
VP OF OPERATIONS
Authorized Official Telephone Number:
904-998-7000

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  DN15716 , 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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