Provider Demographics
NPI:1992078398
Name:CSSS HOLDINGS OF ORANGE PARK, INC.
Entity type:Organization
Organization Name:CSSS HOLDINGS OF ORANGE PARK, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWMER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:J
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-738-7735
Mailing Address - Street 1:4131 UNIVERSITY BLVD S STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4346
Mailing Address - Country:US
Mailing Address - Phone:904-738-7735
Mailing Address - Fax:904-738-7856
Practice Address - Street 1:4131 UNIVERSITY BLVD S STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4346
Practice Address - Country:US
Practice Address - Phone:904-738-7735
Practice Address - Fax:904-738-7856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13959122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty