=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568370104
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLTIDE ORTHODONTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2026
-----------------------------------------------------
Last Update Date | 09/01/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 PASEO REYES DR
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32095-8558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-671-6996
-----------------------------------------------------
Fax | 904-671-7002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 420 PASEO REYES DR
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32095-8558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-671-6996
-----------------------------------------------------
Fax | 904-671-7002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST
-----------------------------------------------------
Name | DR. SUSAN SARA PODRAY
-----------------------------------------------------
Credential | DMD, MS
-----------------------------------------------------
Telephone | 678-787-3863
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------