Provider Demographics
NPI:1376579367
Name:PRINCE, KEVIN TYRONE (DMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:TYRONE
Last Name:PRINCE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 RIVER BRANCH CT
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-1995
Mailing Address - Country:US
Mailing Address - Phone:757-806-0180
Mailing Address - Fax:
Practice Address - Street 1:205 RIVERTOWN SHOPS DR STE 104
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-7476
Practice Address - Country:US
Practice Address - Phone:757-806-0180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN132741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice