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  5. AMELIA DENTAL GROUP, PLLC

AMELIA DENTAL GROUP, PLLC

Company Details

Entity Name: AMELIA DENTAL GROUP, PLLC
Jurisdiction: FLORIDA
Filing Type: Florida Limited Liability Company
Status: Active
Date Filed: 15 Oct 2015 (9 years ago)
Last Event: LC AMENDMENT
Event Date Filed: 23 Jan 2024 (a year ago)
Document Number: L15000175409
FEI/EIN Number 47-5341164
Address: 1947 CITRONA DR, FERNANDINA BEACH, FL 32034
Mail Address: 1947 CITRONA DR, FERNANDINA BEACH, FL 32034
ZIP code: 32034
County: Nassau
Place of Formation: FLORIDA

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1649350349 2006-10-17 2015-12-21 1947 CITRONA DRIVE, FERNANDINA BEACH, FL, 32034, US 1947 CITRONA DRIVE, FERNANDINA BEACH, FL, 32034, US

Contacts
Phone +1 904-261-7181
Fax 9042619797

Authorized person
Name DR. LAURIE KITSON
Role SEC
Phone 9042617181

Taxonomy
Taxonomy Code 122300000X - Dentist
License Number DN15429
State FL
Is Primary Yes
Taxonomy Code 122300000X - Dentist
License Number DN3529
State FL
Is Primary No
Taxonomy Code 122300000X - Dentist
License Number DN17599
State FL
Is Primary No
Taxonomy Code 122300000X - Dentist
License Number DN20603
State FL
Is Primary No
Taxonomy Code 122300000X - Dentist
License Number DN21208
State FL
Is Primary No
Taxonomy Code 1223E0200X - Endodontist
License Number DN11327
State FL
Is Primary No

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
AMELIA DENTAL GROUP, PLLC 401(K) PROFIT SHARING PLAN AND TRUST 2022 475341164 2023-10-12 AMELIA DENTAL GROUP, PLLC 45
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1981-07-01
Business code 621210
Sponsor’s telephone number 9042617181
Plan sponsor’s address 1947 CITRONA DRIVE, BUILDING B, FERNANDINA BEACH, FL, 32034
AMELIA DENTAL GROUP, PLLC 401(K) PROFIT SHARING PLAN AND TRUST 2021 475341164 2022-10-12 AMELIA DENTAL GROUP, PLLC 44
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1981-07-01
Business code 621210
Sponsor’s telephone number 9042617181
Plan sponsor’s address 1947 CITRONA DRIVE, BUILDING B, FERNANDINA BEACH, FL, 320344492
AMELIA DENTAL GROUP, PLLC 401(K) PROFIT SHARING PLAN AND TRUST 2020 475341164 2021-10-11 AMELIA DENTAL GROUP, PLLC 42
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1981-07-01
Business code 621210
Sponsor’s telephone number 9042617181
Plan sponsor’s address 1947 CITRONA DRIVE, BUILDING B, FERNANDINA BEACH, FL, 320344492

Signature of
Role Plan administrator
Date 2021-10-11
Name of individual signing JOSHUA BIETENHOLZ
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2021-10-11
Name of individual signing JOSHUA BIETENHOLZ
Valid signature Filed with authorized/valid electronic signature
AMELIA DENTAL GROUP, PLLC 401(K) PROFIT SHARING PLAN AND TRUST 2019 475341164 2020-06-30 AMELIA DENTAL GROUP, PLLC 38
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1981-07-01
Business code 621210
Sponsor’s telephone number 9042617181
Plan sponsor’s address 1947 CITRONA DRIVE, BUILDING B, FERNANDINA BEACH, FL, 320344492

Signature of
Role Plan administrator
Date 2020-06-30
Name of individual signing JOSHUA BIETENHOLZ
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2020-06-30
Name of individual signing JOSHUA BIETENHOLZ
Valid signature Filed with authorized/valid electronic signature
AMELIA DENTAL GROUP, PLLC 401(K) PROFIT SHARING PLAN AND TRUST 2018 475341164 2019-04-25 AMELIA DENTAL GROUP, PLLC 39
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1981-07-01
Business code 621210
Sponsor’s telephone number 9042617181
Plan sponsor’s address 1947 CITRONA DRIVE, BUILDING B, FERNANDINA BEACH, FL, 320344492

Signature of
Role Plan administrator
Date 2019-04-25
Name of individual signing JOSHUA BIETENHOLZ
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2019-04-25
Name of individual signing JOSHUA BIETENHOLZ
Valid signature Filed with authorized/valid electronic signature
AMELIA DENTAL GROUP, PLLC 401(K) PROFIT SHARING PLAN AND TRUST 2017 475341164 2018-05-21 AMELIA DENTAL GROUP, PLLC 37
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1981-07-01
Business code 621210
Sponsor’s telephone number 9042617181
Plan sponsor’s address 1947 CITRONA DRIVE, BUILDING B, FERNANDINA BEACH, FL, 320344492

Signature of
Role Plan administrator
Date 2018-05-21
Name of individual signing JOSHUA BIETENHOLV
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2018-05-21
Name of individual signing JOSHUA BIETENHOLV
Valid signature Filed with authorized/valid electronic signature
AMELIA DENTAL GROUP, PLLC 401(K) PROFIT SHARING PLAN AND TRUST 2016 475341164 2017-05-17 AMELIA DENTAL GROUP, PLLC 35
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1981-07-01
Business code 621210
Sponsor’s telephone number 9042617181
Plan sponsor’s address 1947 CITRONA DRIVE, BUILDING B, FERNANDINA BEACH, FL, 320344492

Signature of
Role Plan administrator
Date 2017-05-17
Name of individual signing JOSHUA BIETENHOLZ
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2017-05-17
Name of individual signing JOSHUA BIETENHOLZ
Valid signature Filed with authorized/valid electronic signature
AMELIA DENTAL GROUP, PLLC 401(K) PROFIT SHARING PLAN AND TRUST 2015 592097256 2016-09-13 AMELIA DENTAL GROUP, PLLC 35
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1981-07-01
Business code 621210
Sponsor’s telephone number 9042617181
Plan sponsor’s address 1947 CITRONA DRIVE, BUILDING B, FERNANDINA BEACH, FL, 320344492

Signature of
Role Plan administrator
Date 2016-09-13
Name of individual signing JOSHUA BIETENHOLZ
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2016-09-13
Name of individual signing JOSHUA BIETENHOLZ
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role Address
Mokris, Jennifer L, DMD Agent 1947 CITRONA DR, FERNANDINA BEACH, FL 32034

Manager

Name Role Address
BIETENHOLZ, JOSHUA O, DMD Manager 1947 CITRONA DR, FERNANDINA BEACH, FL 32034
Blazejewski, Justin E, DMD Manager 1947 CITRONA DR, FERNANDINA BEACH, FL 32034
GARRETT, STEVEN A, DMD Manager 1947 CITRONA DR, FERNANDINA BEACH, FL 32034
MOKRIS, JENNIFER L, DMD Manager 1947 CITRONA DR, FERNANDINA BEACH, FL 32034
JUSTIN E.BLAZEJEWSKI,DMD Manager 1947 CITRONA DR, FERNANDINA BEACH, FL 32034

Events

Event Type Filed Date Value Description
LC AMENDMENT 2024-01-23 No data No data
CHANGE OF PRINCIPAL ADDRESS 2024-01-22 1947 CITRONA DR, FERNANDINA BEACH, FL 32034 No data
CHANGE OF MAILING ADDRESS 2024-01-22 1947 CITRONA DR, FERNANDINA BEACH, FL 32034 No data
REGISTERED AGENT NAME CHANGED 2024-01-22 Mokris, Jennifer L, DMD No data
REGISTERED AGENT ADDRESS CHANGED 2024-01-22 1947 CITRONA DR, FERNANDINA BEACH, FL 32034 No data
LC AMENDMENT 2019-10-28 No data No data

Documents

Name Date
LC Amendment 2024-01-23
ANNUAL REPORT 2024-01-22
ANNUAL REPORT 2023-03-14
ANNUAL REPORT 2022-02-18
ANNUAL REPORT 2021-02-12
ANNUAL REPORT 2020-02-21
LC Amendment 2019-10-28
ANNUAL REPORT 2019-03-13
ANNUAL REPORT 2018-02-16
ANNUAL REPORT 2017-01-27

Related by officers

BIETENHOLZ, JOSHUA O, DMD

JOSHUA O. BIETENHOLZ, DMD, PLLC

GARRETT, STEVEN A, DMD

STEVEN A. GARRETT, DMD, PLLC

Related by address

1947 CITRONA DR, FERNANDINA BEACH, FL 32034

LAURIE A. KITSON, DMD, PLLC JENNIFER L. MOKRIS, D.M.D., P.A. JUSTIN E. BLAZEJEWSKI, P.L.L.C. D2 CORPORATION

1947 CITRONA DR, FERNANDINA BEACH, FL 32034

LAURIE A. KITSON, DMD, PLLC JENNIFER L. MOKRIS, D.M.D., P.A. JUSTIN E. BLAZEJEWSKI, P.L.L.C. D2 CORPORATION

Date of last update: 20 Jan 2025

Sources: Florida Department of State

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