Provider Demographics
NPI:1962147686
Name:JACKSONVILLE EMERGENCY DENTAL NORTH, PLLC
Entity type:Organization
Organization Name:JACKSONVILLE EMERGENCY DENTAL NORTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:THOMASINO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-891-6691
Mailing Address - Street 1:789 MILL STREAM RD
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4148
Mailing Address - Country:US
Mailing Address - Phone:904-891-6691
Mailing Address - Fax:904-263-4560
Practice Address - Street 1:1840 DUNN AVE STE 3
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4785
Practice Address - Country:US
Practice Address - Phone:904-224-0046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty