Provider Demographics
NPI:1699432468
Name:ORTHO 99 PLUS 1 BARTRAM PARK LLC
Entity type:Organization
Organization Name:ORTHO 99 PLUS 1 BARTRAM PARK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-640-8599
Mailing Address - Street 1:7410 MERRILL RD STE 2
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-6547
Mailing Address - Country:US
Mailing Address - Phone:904-619-7140
Mailing Address - Fax:
Practice Address - Street 1:13920 OLD SAINT AUGUSTINE RD STE 103
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5562
Practice Address - Country:US
Practice Address - Phone:904-640-8599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORTHO 99 PLUS 1
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-11-29
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty