Provider Demographics
NPI:1497560023
Name:PONTE VEDRA ORTHODONTICS LLC
Entity type:Organization
Organization Name:PONTE VEDRA ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MERRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:REFUERZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-609-7241
Mailing Address - Street 1:3109 SAWGRASS VILLAGE CIR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-5032
Mailing Address - Country:US
Mailing Address - Phone:904-273-9115
Mailing Address - Fax:904-871-8116
Practice Address - Street 1:3109 SAWGRASS VILLAGE CIR
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-5032
Practice Address - Country:US
Practice Address - Phone:904-273-9115
Practice Address - Fax:904-871-8116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty