| Entity Name: | BRUSHES AND BRACKETS DENTAL STUDIO INC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 03 Apr 2019 (6 years ago) |
| Document Number: | P19000029976 |
| FEI/EIN Number | 84-3019513 |
| Mail Address: | 2255 DUNN AVE, STE 700, JACKSONVILLE, FL, 32218, US |
| Address: | 2255 DUNN AVENUE, BUILDING 700, JACKSONVILLE, FL, 32225 |
| ZIP code: | 32225 |
| County: | Duval |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1023772704 | 2021-10-28 | 2021-10-28 | 2255 DUNN AVE STE 700, JACKSONVILLE, FL, 322184742, US | 2255 DUNN AVE STE 700, JACKSONVILLE, FL, 322184742, US | |||||||||||||||||||||
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| Phone | +1 904-751-5126 |
| Fax | 9047515146 |
Authorized person
| Name | DR. TANYA WALL |
| Role | OWNER |
| Phone | 9047515126 |
Taxonomy
| Taxonomy Code | 261QD0000X - Dental Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 103221100 |
| State | FL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| BRUSHES AND BRACKETS DENTAL STUDIO 401(K) PLA | 2023 | 843019513 | 2024-10-15 | BRUSHES AND BRACKETS DENTAL STUDIO | 10 | |||||||||||||||||||||||||||||||||
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| Role | Plan administrator |
| Date | 2024-10-15 |
| Name of individual signing | TANYA C. WALL, DDS |
| Valid signature | Filed with authorized/valid electronic signature |
| Role | Employer/plan sponsor |
| Date | 2024-10-15 |
| Name of individual signing | TANYA C. WALL, DDS |
| Valid signature | Filed with authorized/valid electronic signature |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 2022-01-01 |
| Business code | 621210 |
| Sponsor’s telephone number | 9046101922 |
| Plan sponsor’s address | 2255 DUNN AVE, STE 700, JACKSONVILLE, FL, 32218 |
Signature of
| Role | Plan administrator |
| Date | 2024-07-16 |
| Name of individual signing | TANYA C. WALL |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| WALL TANYA C | Agent | 2255 DUNN AVE, JACKSONVILLE, FL, 32218 |
| Name | Role | Address |
|---|---|---|
| Wall Tanya C | President | 2255 DUNN AVE, JACKSONVILLE, FL, 32218 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2022-01-06 | 2255 DUNN AVENUE, BUILDING 700, JACKSONVILLE, FL 32225 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2022-01-06 | 2255 DUNN AVE, STE 700, JACKSONVILLE, FL 32218 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-01-31 |
| ANNUAL REPORT | 2023-02-27 |
| ANNUAL REPORT | 2022-01-06 |
| ANNUAL REPORT | 2021-02-01 |
| ANNUAL REPORT | 2020-03-03 |
| Domestic Profit | 2019-04-03 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
