Basic Information
| Provider Information | |||||||||
| NPI: | 1952756447 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JSK FAMILY DENTAL, P.A. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ASPEN DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3189 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132203189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154546000 | ||||||||
| FaxNumber: | 3154105531 | ||||||||
| Practice Location | |||||||||
| Address1: | 7715 GALL BLVD | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335414315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137824200 | ||||||||
| FaxNumber: | 8137828523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2016 | ||||||||
| LastUpdateDate: | 05/03/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VAN CAMP | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3154546000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN19816 | FL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.