Provider Demographics
NPI:1861179574
Name:MARGOLIS, ALAN
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:MARGOLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 NAUTICA DR UNIT 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-7222
Mailing Address - Country:US
Mailing Address - Phone:904-423-4014
Mailing Address - Fax:
Practice Address - Street 1:651 NAUTICA DR UNIT 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-7222
Practice Address - Country:US
Practice Address - Phone:904-423-4014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-04
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN29498122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist