Provider Demographics
NPI:1336586577
Name:PONTE VEDRA DENTAL GROUP
Entity Type:Organization
Organization Name:PONTE VEDRA DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WINTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-285-8407
Mailing Address - Street 1:330 A1A N STE 326
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32082-1827
Mailing Address - Country:US
Mailing Address - Phone:904-273-8881
Mailing Address - Fax:904-285-5346
Practice Address - Street 1:330 A1A N STE 326
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082-1827
Practice Address - Country:US
Practice Address - Phone:904-273-8881
Practice Address - Fax:904-285-5346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10201122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty