Provider Demographics
NPI:1548764707
Name:OCEANSIDE ENDODONTICS OD ST. AUGUSTINE
Entity Type:Organization
Organization Name:OCEANSIDE ENDODONTICS OD ST. AUGUSTINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:WELDON
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-217-7012
Mailing Address - Street 1:2510 U.S. 1 SOUTH
Mailing Address - Street 2:SUITE B
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086
Mailing Address - Country:US
Mailing Address - Phone:904-217-7012
Mailing Address - Fax:904-217-7924
Practice Address - Street 1:2510 U.S. 1 SOUTH
Practice Address - Street 2:SUITE B
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086
Practice Address - Country:US
Practice Address - Phone:904-217-7012
Practice Address - Fax:904-217-7924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty