MEDICARE: PONTE VEDRA FAMILY DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0700X	Prosthodontics	DN19732	FL
2	1223P0221X	Pediatric Dentistry	DN19731	FL
3	1223G0001X	General Practice Dentistry	DN19732	FL

General Provider Information

NPI Number	:	1700271053
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PONTE VEDRA FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	7000 SAWGRASS VILLAGE CIR
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-5014
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7000 SAWGRASS VILLAGE CIR
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-5014
Country	:	US
Telephone Number	:	904-280-1200
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOSHUA EDWARD PERRY
Credential	:	DMD
Telephone Number	:	904-280-1200

Provider Enumeration Date	:	04/03/2015
Last Update Date	:	06/22/2015

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