Provider Demographics
NPI:1265955611
Name:LE, PAULINE (DMD)
Entity type:Individual
Prefix:DR
First Name:PAULINE
Middle Name:
Last Name:LE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14030 ATLANTIC BLVD UNIT 2212
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-3896
Mailing Address - Country:US
Mailing Address - Phone:904-881-4771
Mailing Address - Fax:
Practice Address - Street 1:1845 EASTWEST PKWY STE 3
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-6405
Practice Address - Country:US
Practice Address - Phone:904-278-7308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN22819122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist