Organization
JACKSONVILLE DENTISTRY PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PETER KELLY (OWNER)
(410) 410-3031
Entity
Organization
Contact information
Practice address
12058 SAN JOSE BLVD STE 102, JACKSONVILLE, FL 32223-8669
(904) 880-3131
Mailing address
12058 SAN JOSE BLVD STE 102, JACKSONVILLE, FL 32223-8669
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
DN0013386
STATE LICENSE
FL
01
—
DN19430
STATE LICENSE
FL
01
—
DN21484
STATE LICENSE
FL
Enumeration date
02/24/2021
Last updated
02/24/2021
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