Basic Information
| Provider Information | |||||||||
| NPI: | 1730636903 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | US NAVY | ||||||||
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| Mailing Information | |||||||||
| Address1: | BLDG H 2005 KNIGHT LANE | ||||||||
| Address2: | NAVY MEDICINE SUPPORT COMMAND ATTN: MEDICAL STAFF SVCS | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322120140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607253213 | ||||||||
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| Practice Location | |||||||||
| Address1: | BLDG H 2005 KNIGHT LANE | ||||||||
| Address2: | NAVY MEDICINE SUPPORT COMMAND ATTN: MEDICAL STAFF SVCS | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322120140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607255419 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2016 | ||||||||
| LastUpdateDate: | 09/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | RODNEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DENTAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9017343785 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | DN05164 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.