Provider Demographics
NPI:1194235689
Name:JACKSONVILLE COMPLETE DENTISTRY PLLC
Entity type:Organization
Organization Name:JACKSONVILLE COMPLETE DENTISTRY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-751-4958
Mailing Address - Street 1:7740 POINT MEADOWS DR
Mailing Address - Street 2:SUITES 4 & 5
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-645-6457
Mailing Address - Fax:904-645-6459
Practice Address - Street 1:7740 POINT MEADOWS DR
Practice Address - Street 2:SUITES 4 & 5
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:904-645-6457
Practice Address - Fax:904-645-6459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty