Basic Information
| Provider Information | |||||||||
| NPI: | 1295231819 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LARROC DENTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7768 OZARK DR | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322565839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044426000 | ||||||||
| FaxNumber: | 9045031440 | ||||||||
| Practice Location | |||||||||
| Address1: | 7768 OZARK DR | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322565839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044426000 | ||||||||
| FaxNumber: | 9045031440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2018 | ||||||||
| LastUpdateDate: | 04/03/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CORRAL | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9044426000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN2788 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223G0001X | DN14472 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 124Q00000X | DH23171 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Hygienist | 124Q00000X | DH9959 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Hygienist | 124Q00000X | DH24089 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dental Hygienist | 1223G0001X | DN17063 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1992831341 | 05 | FL | MEDICAID | 1275513434 | 05 | FL | MEDICAID | 1730600958 | 05 | FL | MEDICAID |