Healthcare Provider Details

I. General information

NPI: 1720463714
Provider Name (Legal Business Name): SALT RUN FAMILY DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2015
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 ANASTASIA BLVD
SAINT AUGUSTINE FL
32080-4616
US

IV. Provider business mailing address

700 ANASTASIA BLVD
SAINT AUGUSTINE FL
32080-4616
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-3540
  • Fax: 904-824-3541
Mailing address:
  • Phone: 904-824-3540
  • Fax: 904-824-3541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN18649
License Number StateFL

VIII. Authorized Official

Name: DR. VINCENT MICHAEL LETH II
Title or Position: OWNER
Credential: DMD
Phone: 904-824-3540