Provider Demographics
NPI:1114641339
Name:GUIDED SMILES PROSTHODONTICS & IMPLANT CENTER PLLC
Entity Type:Organization
Organization Name:GUIDED SMILES PROSTHODONTICS & IMPLANT CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:ALONZO
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-395-5501
Mailing Address - Street 1:153 FORT WADE ROAD
Mailing Address - Street 2:STE 100
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:153 FORT WADE ROAD
Practice Address - Street 2:STE 100
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081
Practice Address - Country:US
Practice Address - Phone:904-395-5501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental