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General NPI Number Information
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NPI Number | 1548764707
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Entity Type | Organization
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Legal Business Name | OCEANSIDE ENDODONTICS OD ST. AUGUSTINE
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Dates
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Enumeration Date | 03/22/2018
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Last Update Date | 03/22/2018
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Provider Practice Location Address
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Address Line | 2510 U.S. 1 SOUTH SUITE B
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City | ST. AUGUSTINE
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State | FL
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Zip | 32086
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Country | US
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Telephone | 904-217-7012
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Fax | 904-217-7924
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Provider Business Mailing Address
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Address Line | 2510 U.S. 1 SOUTH SUITE B
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City | ST. AUGUSTINE
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State | FL
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Zip | 32086
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Country | US
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Telephone | 904-217-7012
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Fax | 904-217-7924
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Authorized Official
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Title or Position | OWNER
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Name | EMILY WELDON TYLER
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Credential | DMD
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Telephone | 904-217-7012
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number |
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License Number State |
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