Healthcare Provider Details

I. General information

NPI: 1700271053
Provider Name (Legal Business Name): PONTE VEDRA FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2015
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 SAWGRASS VILLAGE CIR
PONTE VEDRA BEACH FL
32082-5014
US

IV. Provider business mailing address

7000 SAWGRASS VILLAGE CIR
PONTE VEDRA BEACH FL
32082-5014
US

V. Phone/Fax

Practice location:
  • Phone: 904-280-1200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN19732
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN19731
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDN19732
License Number StateFL

VIII. Authorized Official

Name: DR. JOSHUA EDWARD PERRY
Title or Position: PRESIDENT
Credential: DMD
Phone: 904-280-1200