Healthcare Provider Details

I. General information

NPI: 1942021514
Provider Name (Legal Business Name): SMILE SO BIG FLAGLER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MALAGA ST
ST AUGUSTINE FL
32084-3521
US

IV. Provider business mailing address

150 MALAGA ST
ST AUGUSTINE FL
32084-3521
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-9024
  • Fax:
Mailing address:
  • Phone:
  • 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: JONATHAN AALONA MONTOYA
Title or Position: OWNER
Credential: DDS
Phone: 904-829-9024