1821144205 NPI number — MARK EVERETT DAWLEY DMD

Table of content: MARK EVERETT DAWLEY DMD (NPI 1821144205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821144205 NPI number — MARK EVERETT DAWLEY DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAWLEY
Provider First Name:
MARK
Provider Middle Name:
EVERETT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

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:
1821144205
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2015
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:
449621 US HIGHWAY 301
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
CALLAHAN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32011-9348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-879-1893
Provider Business Practice Location Address Fax Number:
904-879-6448
Provider Enumeration Date:
01/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DN12304 , 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: 106180800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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