Healthcare Provider Details

I. General information

NPI: 1316584808
Provider Name (Legal Business Name): GLENOS AND HADGIS ORTHODONTICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2019
Last Update Date: 01/12/2020
Certification Date: 01/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 SAINT JOHNS MEDICAL PARK DR
SAINT AUGUSTINE FL
32086-5299
US

IV. Provider business mailing address

22 SAINT JOHNS MEDICAL PARK DR
SAINT AUGUSTINE FL
32086-5299
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-6453
  • Fax:
Mailing address:
  • Phone: 904-797-6453
  • Fax:

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: DR. CRAIG HADGIS
Title or Position: PARTNER
Credential: DDS
Phone: 313-283-1883