Provider Demographics
NPI:1649820630
Name:PONTE VEDRA ENDODONTICS
Entity type:Organization
Organization Name:PONTE VEDRA ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:C
Authorized Official - Last Name:MAVEC
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:904-273-5770
Mailing Address - Street 1:822 A1A NORTH
Mailing Address - Street 2:STE 314
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082
Mailing Address - Country:US
Mailing Address - Phone:904-273-5770
Mailing Address - Fax:904-701-6252
Practice Address - Street 1:822 A1A NORTH
Practice Address - Street 2:STE 314
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082
Practice Address - Country:US
Practice Address - Phone:904-273-5770
Practice Address - Fax:904-701-6252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty