Provider Demographics
NPI:1386876084
Name:DEFELICE, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DEFELICE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:HUCKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:2225 A1A S STE A3
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6374
Mailing Address - Country:US
Mailing Address - Phone:904-471-7300
Mailing Address - Fax:904-471-2708
Practice Address - Street 1:2225 A1A S STE A3
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-6374
Practice Address - Country:US
Practice Address - Phone:904-471-7300
Practice Address - Fax:904-471-2708
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16151122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist