Healthcare Provider Details

I. General information

NPI: 1568370104
Provider Name (Legal Business Name): WELLTIDE ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 PASEO REYES DR
ST AUGUSTINE FL
32095-8558
US

IV. Provider business mailing address

420 PASEO REYES DR
ST AUGUSTINE FL
32095-8558
US

V. Phone/Fax

Practice location:
  • Phone: 904-671-6996
  • Fax: 904-671-7002
Mailing address:
  • Phone: 904-671-6996
  • Fax: 904-671-7002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. SUSAN SARA PODRAY
Title or Position: ORTHODONTIST
Credential: DMD, MS
Phone: 678-787-3863