Professional Dental Alliance of Jacksonville San Jose, PLLC

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

Legal business name

PROFESSIONAL DENTAL ALLIANCE OF JACKSONVILLE SAN JOSE, PLLC

Practice address

9776 San Jose Blvd Ste 7
Jacksonville, FL 32257-5464

Phone

(904) 201-3565

NPI assigned

Sep 16, 2019

Last updated

Sep 16, 2019By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Lauren Howard, MA

Title

Credentialing Specialist

Phone

(757) 576-5479

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1568592000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1568592000000",
    "number": "1578113254",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11 S MILL ST STE 200",
            "city": "NEW CASTLE",
            "state": "PA",
            "postal_code": "161013680"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9776 SAN JOSE BLVD STE 7",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322575464",
            "telephone_number": "904-201-3565"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROFESSIONAL DENTAL ALLIANCE OF JACKSONVILLE SAN JOSE, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-09-16",
        "last_updated": "2019-09-16",
        "status": "A",
        "authorized_official_last_name": "HOWARD",
        "authorized_official_first_name": "LAUREN",
        "authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "757-576-5479",
        "authorized_official_credential": "MA"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• General Practice Dentistry in Jacksonville, FL
• Providers in Jacksonville, FL by specialty
• General Practice Dentistry in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 16, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.