Healthcare Provider Details

I. General information

NPI: 1659251882
Provider Name (Legal Business Name): LIGHTHOUSE DENTAL STUDIO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 09/08/2025
Certification Date: 09/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 ASHOURIAN AVE UNIT 217-218
ST AUGUSTINE FL
32092-5108
US

IV. Provider business mailing address

206 ASHOURIAN AVE UNIT 217-218
ST AUGUSTINE FL
32092-5108
US

V. Phone/Fax

Practice location:
  • Phone: 407-961-2821
  • Fax:
Mailing address:
  • Phone: 407-961-2821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RYAN COLAIANNI
Title or Position: OWNER/DENTIST
Credential: DMD
Phone: 407-961-2821