Healthcare Provider Details

I. General information

NPI: 1023834561
Provider Name (Legal Business Name): AP DENTAL BAYMEADOWS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/02/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 MAHI DR
PONTE VEDRA FL
32081-1530
US

IV. Provider business mailing address

613 MAHI DR
PONTE VEDRA FL
32081-1530
US

V. Phone/Fax

Practice location:
  • Phone: 978-223-3742
  • Fax:
Mailing address:
  • Phone: 978-223-3742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ANNA PUKHOVITSKAYA
Title or Position: DENTIST
Credential: DMD
Phone: 978-223-3742