Basic Information
| Provider Information | |||||||||
| NPI: | 1760834980 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNITED STATED NAVY | ||||||||
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| Mailing Information | |||||||||
| Address1: | BLDG H 2005 KNIGHT LANE | ||||||||
| Address2: | NAVY MEDICINE SUPPORT SUPPORT COMMAND ATTN: MEDICAL STA | ||||||||
| 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 SUPPORT COMMAND ATTN: MEDICAL STA | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322120140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607253213 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2016 | ||||||||
| LastUpdateDate: | 07/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | JUSTIN | ||||||||
| AuthorizedOfficialMiddleName: | ROGER | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 7702419192 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 8727 | SC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.