Provider Demographics
NPI:1538322441
Name:ST. JOHNS FAMILY DENTISTRY
Entity Type:Organization
Organization Name:ST. JOHNS FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:R
Authorized Official - Last Name:CORRAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-442-6000
Mailing Address - Street 1:2225 A1A SOUTH SUITE A3
Mailing Address - Street 2:
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6374
Mailing Address - Country:US
Mailing Address - Phone:904-471-7300
Mailing Address - Fax:904-471-2708
Practice Address - Street 1:2225 A1A S STE A3
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080
Practice Address - Country:US
Practice Address - Phone:904-471-7300
Practice Address - Fax:904-471-2708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN8386122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty