Provider Demographics
NPI:1396000329
Name:PONTE VEDRA COSMETIC DENTISTRY, PA
Entity type:Organization
Organization Name:PONTE VEDRA COSMETIC DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAMALA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-285-8407
Mailing Address - Street 1:100 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-6216
Mailing Address - Country:US
Mailing Address - Phone:904-285-8407
Mailing Address - Fax:904-285-5346
Practice Address - Street 1:100 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-6216
Practice Address - Country:US
Practice Address - Phone:904-285-8407
Practice Address - Fax:904-285-5346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty