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General NPI Number Information
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NPI Number | 1396000329
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Entity Type | Organization
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Legal Business Name | PONTE VEDRA COSMETIC DENTISTRY, PA
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Dates
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Enumeration Date | 07/05/2012
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Last Update Date | 07/05/2012
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Provider Practice Location Address
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Address Line | 100 PROFESSIONAL DR
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City | PONTE VEDRA BEACH
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State | FL
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Zip | 32082-6216
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Country | US
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Telephone | 904-285-8407
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Fax | 904-285-5346
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Provider Business Mailing Address
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Address Line | 100 PROFESSIONAL DR
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City | PONTE VEDRA BEACH
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State | FL
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Zip | 32082-6216
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Country | US
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Telephone | 904-285-8407
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Fax | 904-285-5346
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | MRS. KAMALA RUDOLPH
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Credential |
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Telephone | 904-285-8407
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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