| Entity Name: | NORTH FLORIDA ORAL AND FACIAL SURGERY, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 01 Apr 1988 (37 years ago) |
| Document Number: | K19925 |
| FEI/EIN Number | 592880470 |
| Address: | 11481 OLD ST. AUGUSTINE ROAD, SUITE 203, JACKSONVILLE, FL, 32258, US |
| Mail Address: | 11481 OLD ST. AUGUSTINE ROAD, SUITE 203, JACKSONVILLE, FL, 32258, US |
| ZIP code: | 32258 |
| County: | Duval |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1851417406 | 2007-03-22 | 2018-01-12 | 11481 OLD ST. AUGUSTINE ROAD STE. 203, JACKSONVILLE, FL, 322581475, US | 11481 OLD SAINT AUGUSTINE RD STE 203, JACKSONVILLE, FL, 322581475, US | |||||||||||||||||
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| Phone | +1 904-309-5951 |
| Fax | 9047378326 |
| Phone | +1 904-309-5651 |
Authorized person
| Name | DR. RICK CRICI |
| Role | EXECUTIVE DIRECTOR |
| Phone | 9047373617 |
Taxonomy
| Taxonomy Code | 1223S0112X - Oral and Maxillofacial Surgery (Dentist) |
| Is Primary | Yes |
| Name | Role |
|---|---|
| GLAZIER, GLAZIER & DIETRICH, P.A. | Agent |
| Name | Role | Address |
|---|---|---|
| SKLENICKA SCOTT RDMD, MD | Director | 11481 OLD ST. AUGUSTINE ROAD, SUITE 203, JACKSONVILLE, FL, 32258 |
| JOHN J MAZZUOCCOLO, DMD, MD | Director | 11481 OLD ST. AUGUSTINE ROAD, SUITE 203, JACKSONVILLE, FL, 32258 |
| Farrell Thomas RDDS | Director | 11481 OLD ST. AUGUSTINE ROAD, SUITE 203, JACKSONVILLE, FL, 32258 |
| Wahl Tyler MDMD, MD | Director | 11481 OLD ST. AUGUSTINE ROAD, SUITE 203, JACKSONVILLE, FL, 32258 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G08060700016 | PONTE VEDRA BEACH ORAL & MAXILLOFACIAL SURGERY | EXPIRED | 2008-02-29 | 2013-12-31 | No data | 115 PROFESSIONAL DR STE 105, PONTE VEDRA BEACH, FL, 32082 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| AMENDMENT | 2018-10-04 | No data | No data |
| AMENDMENT AND NAME CHANGE | 1996-01-05 | NORTH FLORIDA ORAL AND FACIAL SURGERY, P.A. | No data |
| NAME CHANGE AMENDMENT | 1990-01-18 | DRS. CHERRY AND HARTLEY, P.A. | No data |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
