Healthcare Provider Details

I. General information

NPI: 1962750935
Provider Name (Legal Business Name): ATLANTIC COAST PROSTHODONTICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2012
Last Update Date: 08/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 MASON AVE
DAYTONA BEACH FL
32117-4548
US

IV. Provider business mailing address

1509 MASON AVE
DAYTONA BEACH FL
32117-4548
US

V. Phone/Fax

Practice location:
  • Phone: 386-239-7600
  • Fax:
Mailing address:
  • Phone: 386-239-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN 10669
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN WHITSITT
Title or Position: OWNER
Credential: D.D.S.
Phone: 386-239-7600