Healthcare Provider Details

I. General information

NPI: 1538533674
Provider Name (Legal Business Name): AFFORDABLE BRACES OF NORTH FLORIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2015
Last Update Date: 11/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 W TWINCOURT TRL SUITE 602
ST AUGUSTINE FL
32095-8805
US

IV. Provider business mailing address

559 W TWINCOURT TRL SUITE 602
ST AUGUSTINE FL
32095-8805
US

V. Phone/Fax

Practice location:
  • Phone: 404-414-0106
  • Fax:
Mailing address:
  • Phone: 404-414-0106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN19187
License Number StateFL

VIII. Authorized Official

Name: DR. JASON P OUELLETTE
Title or Position: OWNER - ORTHODONTIST
Credential: DDS
Phone: 404-414-0106