Provider Demographics
NPI:1144655143
Name:CHAVES, STEPHANIE BURGESS (DDS)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BURGESS
Last Name:CHAVES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2054 RIVERSIDE AVE
Mailing Address - Street 2:APT. 5207
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4428
Mailing Address - Country:US
Mailing Address - Phone:304-290-2722
Mailing Address - Fax:
Practice Address - Street 1:10601 SAN JOSE BLVD
Practice Address - Street 2:SUITE 116
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-8232
Practice Address - Country:US
Practice Address - Phone:904-483-3027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN203981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009691200Medicaid