Provider Demographics
NPI:1922312354
Name:BEACHES ORTHODONTICS, P.A.
Entity Type:Organization
Organization Name:BEACHES ORTHODONTICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:O'SHAUGHNESSY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:904-273-5570
Mailing Address - Street 1:330 AIA NORTH
Mailing Address - Street 2:SUITE 326
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082
Mailing Address - Country:US
Mailing Address - Phone:904-273-5570
Mailing Address - Fax:904-273-8518
Practice Address - Street 1:330 AIA NORTH
Practice Address - Street 2:SUITE 326
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082
Practice Address - Country:US
Practice Address - Phone:904-273-5570
Practice Address - Fax:904-273-8518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN168011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty