Healthcare Provider Details

I. General information

NPI: 1548764707
Provider Name (Legal Business Name): OCEANSIDE ENDODONTICS OD ST. AUGUSTINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 U.S. 1 SOUTH SUITE B
ST. AUGUSTINE FL
32086
US

IV. Provider business mailing address

2510 U.S. 1 SOUTH SUITE B
ST. AUGUSTINE FL
32086
US

V. Phone/Fax

Practice location:
  • Phone: 904-217-7012
  • Fax: 904-217-7924
Mailing address:
  • Phone: 904-217-7012
  • Fax: 904-217-7924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: EMILY WELDON TYLER
Title or Position: OWNER
Credential: DMD
Phone: 904-217-7012