Organization
MYERS PEDIATRIC DENTISTRY PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GARY MYERS DMD (PRESIDENT)
(904) 505-2010
Entity
Organization
Contact information
Practice address
3200 OLD JENNINGS RD, MIDDLEBURG, FL 32068-3414
(904) 505-2010
(904) 505-2011
Mailing address
3200 OLD JENNINGS RD, MIDDLEBURG, FL 32068-3414
(904) 505-2010
(904) 505-2011
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
—
—
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1770740
UNITED CONCORDIA
FL
01
—
85410
BLUE CROSS BLUE SHIELD
—
Enumeration date
07/31/2006
Last updated
08/17/2010
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