Healthcare Provider Details

I. General information

NPI: 1275193278
Provider Name (Legal Business Name): STEPHANIE KINSEY DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 PALENCIA VILLAGE DR STE 107-109
ST AUGUSTINE FL
32095-8457
US

IV. Provider business mailing address

159 PALENCIA VILLAGE DR STE 107-109
ST AUGUSTINE FL
32095-8457
US

V. Phone/Fax

Practice location:
  • Phone: 904-826-4343
  • Fax:
Mailing address:
  • Phone: 904-826-4343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE KINSEY
Title or Position: OWNER
Credential: DDS
Phone: 904-826-4343