Healthcare Provider Details

I. General information

NPI: 1316788359
Provider Name (Legal Business Name): YULEE DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463480 STATE ROAD 200
YULEE FL
32097-3370
US

IV. Provider business mailing address

463480 STATE ROAD 200
YULEE FL
32097-3370
US

V. Phone/Fax

Practice location:
  • Phone: 904-468-5135
  • Fax: 407-574-4651
Mailing address:
  • Phone: 407-432-6224
  • Fax: 407-574-4651

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: MR. PETER KELLY
Title or Position: OWNER
Credential:
Phone: 407-432-6224