Healthcare Provider Details

I. General information

NPI: 1497560023
Provider Name (Legal Business Name): PONTE VEDRA ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2025
Last Update Date: 02/11/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3109 SAWGRASS VILLAGE CIR
PONTE VEDRA BEACH FL
32082-5032
US

IV. Provider business mailing address

3109 SAWGRASS VILLAGE CIR
PONTE VEDRA BEACH FL
32082-5032
US

V. Phone/Fax

Practice location:
  • Phone: 904-273-9115
  • Fax: 904-871-8116
Mailing address:
  • Phone: 904-273-9115
  • Fax: 904-871-8116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MERRIAN REFUERZO
Title or Position: BILLING MANAGER
Credential:
Phone: 321-609-7241