Provider Demographics
NPI:1386044790
Name:BETH E. KAILES, DMD, PA
Entity Type:Organization
Organization Name:BETH E. KAILES, DMD, PA
Other - Org Name:PEDIATRIC DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:KAILES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-215-7800
Mailing Address - Street 1:1851 GOLDEN EAGLE WAY
Mailing Address - Street 2:SUITE #36
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1851 GOLDEN EAGLE WAY
Practice Address - Street 2:SUITE #36
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4333
Practice Address - Country:US
Practice Address - Phone:904-215-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL167531223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty