Healthcare Provider Details

I. General information

NPI: 1720380207
Provider Name (Legal Business Name): BELLEAIR ORAL SURGERY AND IMPLANTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2010
Last Update Date: 03/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 INDIAN ROCKS RD N SUITE 12
BELLEAIR BLUFFS FL
33770-1778
US

IV. Provider business mailing address

100 INDIAN ROCKS RD N SUITE 12
BELLEAIR BLUFFS FL
33770-1778
US

V. Phone/Fax

Practice location:
  • Phone: 727-581-3300
  • Fax: 727-581-3302
Mailing address:
  • Phone: 727-581-3300
  • Fax: 727-581-3302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN15139
License Number StateFL

VIII. Authorized Official

Name: DR. RALPH MARK EICHSTAEDT
Title or Position: PRESIDENT/ORAL SURGEON
Credential: D.D.S.
Phone: 727-581-3300