Provider Demographics
NPI:1609293034
Name:PALM LEAF DENTAL
Entity Type:Organization
Organization Name:PALM LEAF DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:EVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-810-5702
Mailing Address - Street 1:100 MARKETSIDE AVENUE, STE 306
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081
Mailing Address - Country:US
Mailing Address - Phone:904-810-5702
Mailing Address - Fax:
Practice Address - Street 1:100 MARKETSIDE AVE STE 306
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-0582
Practice Address - Country:US
Practice Address - Phone:904-810-5702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN181371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty