Healthcare Provider Details

I. General information

NPI: 1477746410
Provider Name (Legal Business Name): ELIZABETH K GESENHUES DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

491 PROSPERITY LAKE DR SUITE 301
ST AUGUSTINE FL
32092-5045
US

IV. Provider business mailing address

491 PROSPERITY LAKE DR SUITE 301
ST AUGUSTINE FL
32092-5045
US

V. Phone/Fax

Practice location:
  • Phone: 904-429-0095
  • Fax: 904-429-0238
Mailing address:
  • Phone: 904-429-0095
  • Fax: 904-429-0238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN00012154
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: