Provider Demographics
NPI:1467283523
Name:OCEANSIDE DENTAL OF JACKSONVILLE
Entity type:Organization
Organization Name:OCEANSIDE DENTAL OF JACKSONVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-716-0415
Mailing Address - Street 1:122 PARADAS PL
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3120
Mailing Address - Country:US
Mailing Address - Phone:208-716-0415
Mailing Address - Fax:
Practice Address - Street 1:7751 BAYMEADOWS RD E STE 108
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5889
Practice Address - Country:US
Practice Address - Phone:208-716-0415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty