Healthcare Provider Details

I. General information

NPI: 1003612730
Provider Name (Legal Business Name): LITTLE LOVE PEDIATRIC DENTISTRY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2025
Last Update Date: 02/24/2025
Certification Date: 02/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 SILVER FOREST DR STE 108
ST AUGUSTINE FL
32092-3836
US

IV. Provider business mailing address

628 SOUTHERN OAK DR
PONTE VEDRA BEACH FL
32081-8368
US

V. Phone/Fax

Practice location:
  • Phone: 904-206-8809
  • Fax:
Mailing address:
  • Phone: 904-206-8809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: AMBER SUN
Title or Position: OWNER
Credential:
Phone: 404-578-5247