| Entity Name: | SOUTH JACKSONVILLE DENTAL PLLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 02 Oct 2015 (9 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 18 Oct 2016 (8 years ago) |
| Document Number: | L15000167934 |
| FEI/EIN Number | 475226445 |
| Address: | 8440 BLANDING BLVD, JACKSONVILLE, FL, 32244, US |
| Mail Address: | PO BOX 634, Ponte Vedra BEACH, FL, 32004, US |
| ZIP code: | 32244 |
| County: | Duval |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1003287814 | 2015-10-20 | 2015-10-20 | 8440 BLANDING BLVD, JACKSONVILLE, FL, 32244, US | 8440 BLANDING BLVD, JACKSONVILLE, FL, 32244, US | |||||||||||||||
|
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| Phone | +1 904-525-8041 |
| Fax | 3154105531 |
Authorized person
| Name | KIM VAN CAMP |
| Role | PROVIDER RELATIONS SPECIALIST |
| Phone | 3154546000 |
Taxonomy
| Taxonomy Code | 1223G0001X - General Practice Dentistry |
| Is Primary | Yes |
| Name | Role | Address |
|---|---|---|
| PARK JONG YUN | Agent | 8440 BLANDING BLVD, JACKSONVILLE, FL, 32244 |
| Name | Role | Address |
|---|---|---|
| Park Jong Yun | owne | 130 Corridor Rd., Ponte Vedra Beach, FL, 32004 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G15000116365 | ASPEN DENTAL | EXPIRED | 2015-11-16 | 2020-12-31 | No data | 8440 BLANDING BLVD, JACKSONVILLE, FL, 32244 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2021-10-04 | 8440 BLANDING BLVD, JACKSONVILLE, FL 32244 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2018-03-18 | 8440 BLANDING BLVD, JACKSONVILLE, FL 32244 | No data |
| REINSTATEMENT | 2016-10-18 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2016-10-18 | PARK, JONG YUN | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2016-09-23 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2025-01-20 |
| ANNUAL REPORT | 2024-01-04 |
| ANNUAL REPORT | 2023-01-22 |
| ANNUAL REPORT | 2022-01-21 |
| ANNUAL REPORT | 2021-01-13 |
| ANNUAL REPORT | 2020-01-18 |
| ANNUAL REPORT | 2019-02-10 |
| ANNUAL REPORT | 2018-03-18 |
| ANNUAL REPORT | 2017-07-08 |
| REINSTATEMENT | 2016-10-18 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
