Healthcare Provider Details

I. General information

NPI: 1801059480
Provider Name (Legal Business Name): PONCE DE LEON FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SAINT JOHNS MEDICAL PK DR
SAINT AUGUSTINE FL
32086-5298
US

IV. Provider business mailing address

4 SAINT JOHNS MEDICAL PK DR
SAINT AUGUSTINE FL
32086-5298
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-9009
  • Fax: 904-797-9057
Mailing address:
  • Phone: 904-797-9009
  • Fax: 904-797-9057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. THEODORE DANIEL HAEUSSNER
Title or Position: DENTIST
Credential:
Phone: 904-797-8247