Provider Demographics
NPI:1801059480
Name:PONCE DE LEON FAMILY DENTISTRY
Entity type:Organization
Organization Name:PONCE DE LEON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:HAEUSSNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-797-8247
Mailing Address - Street 1:4 SAINT JOHNS MEDICAL PK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5298
Mailing Address - Country:US
Mailing Address - Phone:904-797-9009
Mailing Address - Fax:904-797-9057
Practice Address - Street 1:4 SAINT JOHNS MEDICAL PK DR
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5298
Practice Address - Country:US
Practice Address - Phone:904-797-9009
Practice Address - Fax:904-797-9057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental