Provider Demographics
NPI:1790500908
Name:PALM VALLEY FAMILY DENTISTRY, PLLC
Entity type:Organization
Organization Name:PALM VALLEY FAMILY DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MCKENZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WORTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-834-2736
Mailing Address - Street 1:3791 PALM VALLEY RD STE 205
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4180
Mailing Address - Country:US
Mailing Address - Phone:904-834-2736
Mailing Address - Fax:
Practice Address - Street 1:3791 PALM VALLEY RD STE 205
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-4180
Practice Address - Country:US
Practice Address - Phone:904-834-2736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-21
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty