Healthcare Provider Details

I. General information

NPI: 1386294072
Provider Name (Legal Business Name): PROFESSIONAL DENTAL ALLIANCE OF ST. AUGUSTINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 A1A S STE A3
ST AUGUSTINE FL
32080-6374
US

IV. Provider business mailing address

11 S MILL ST STE 200
NEW CASTLE PA
16101-3680
US

V. Phone/Fax

Practice location:
  • Phone: 904-201-3442
  • Fax:
Mailing address:
  • Phone:
  • 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: LAUREN HOWARD
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 757-576-5479