Provider Demographics
NPI:1194191692
Name:PONTE VEDRA PEDIATRIC DENTISTRY AND ORTHODONTICS
Entity Type:Organization
Organization Name:PONTE VEDRA PEDIATRIC DENTISTRY AND ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:G
Authorized Official - Last Name:MAPLES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-880-5437
Mailing Address - Street 1:480 TOWN PLAZA AVENUE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081
Mailing Address - Country:US
Mailing Address - Phone:904-880-5437
Mailing Address - Fax:904-880-1490
Practice Address - Street 1:480 TOWN PLAZA AVENUE
Practice Address - Street 2:SUITE 110
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081
Practice Address - Country:US
Practice Address - Phone:904-880-5437
Practice Address - Fax:904-880-1490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN182711223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty