Provider Demographics
NPI:1649350349
Name:AMELIA DENTAL GROUP, PLLC
Entity type:Organization
Organization Name:AMELIA DENTAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KITSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:904-261-7181
Mailing Address - Street 1:1947 CITRONA DRIVE
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034
Mailing Address - Country:US
Mailing Address - Phone:904-261-7181
Mailing Address - Fax:904-261-9797
Practice Address - Street 1:1947 CITRONA DRIVE
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034
Practice Address - Country:US
Practice Address - Phone:904-261-7181
Practice Address - Fax:904-261-9797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN3529122300000X
FLDN17599122300000X
FLDN20603122300000X
FLDN21208122300000X
FLDN113271223E0200X
FLDN15429122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty