Provider Demographics
NPI:1861162141
Name:ISLANDS EDGE DENTAL, LLC
Entity type:Organization
Organization Name:ISLANDS EDGE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLET
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-461-5566
Mailing Address - Street 1:1301 PLANTATION ISLAND DR S STE 104B
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-3110
Mailing Address - Country:US
Mailing Address - Phone:904-461-5566
Mailing Address - Fax:904-461-0084
Practice Address - Street 1:1301 PLANTATION ISLAND DR S STE 104B
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-3110
Practice Address - Country:US
Practice Address - Phone:904-461-5566
Practice Address - Fax:904-461-0084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental