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General NPI Number Information
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NPI Number | 1720463714
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Entity Type | Organization
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Legal Business Name | SALT RUN FAMILY DENTISTRY, LLC
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Dates
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Enumeration Date | 07/20/2015
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Last Update Date | 07/20/2015
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Provider Practice Location Address
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Address Line | 700 ANASTASIA BLVD
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32080-4616
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Country | US
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Telephone | 904-824-3540
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Fax | 904-824-3541
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Provider Business Mailing Address
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Address Line | 700 ANASTASIA BLVD
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32080-4616
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Country | US
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Telephone | 904-824-3540
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Fax | 904-824-3541
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Authorized Official
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Title or Position | OWNER
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Name | DR. VINCENT MICHAEL LETH II
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Credential | DMD
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Telephone | 904-824-3540
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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 | DN18649
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License Number State | FL
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