Healthcare Provider Details

I. General information

NPI: 1538322441
Provider Name (Legal Business Name): ST. JOHNS FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 A1A S STE A3
ST AUGUSTINE FL
32080
US

IV. Provider business mailing address

2225 A1A SOUTH SUITE A3
ST. AUGUSTINE FL
32080-6374
US

V. Phone/Fax

Practice location:
  • Phone: 904-471-7300
  • Fax: 904-471-2708
Mailing address:
  • Phone: 904-471-7300
  • Fax: 904-471-2708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN8386
License Number StateFL

VIII. Authorized Official

Name: ANTHONY R. CORRAL
Title or Position: DMD
Credential:
Phone: 904-442-6000