Healthcare Provider Details

I. General information

NPI: 1861162141
Provider Name (Legal Business Name): ISLANDS EDGE DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DR S STE 104B
ST AUGUSTINE FL
32080-3110
US

IV. Provider business mailing address

1301 PLANTATION ISLAND DR S STE 104B
ST AUGUSTINE FL
32080-3110
US

V. Phone/Fax

Practice location:
  • Phone: 904-461-5566
  • Fax: 904-461-0084
Mailing address:
  • Phone: 904-461-5566
  • Fax: 904-461-0084

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. ANDREW MULLET
Title or Position: GENERAL DENTIST
Credential: DDS
Phone: 904-461-5566