Provider Demographics
NPI:1205132503
Name:THE VILLAGE DENTIST
Entity type:Organization
Organization Name:THE VILLAGE DENTIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-940-7990
Mailing Address - Street 1:425 W TOWN PL
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3661
Mailing Address - Country:US
Mailing Address - Phone:904-940-7990
Mailing Address - Fax:904-940-7991
Practice Address - Street 1:425 W TOWN PL
Practice Address - Street 2:SUITE 106
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3661
Practice Address - Country:US
Practice Address - Phone:904-940-7990
Practice Address - Fax:904-940-7991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN117141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty