Healthcare Provider Details

I. General information

NPI: 1609770197
Provider Name (Legal Business Name): SKYBLUE WD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2139 SKYLINE BLVD STE B
CAPE CORAL FL
33991-3674
US

IV. Provider business mailing address

2139 SKYLINE BLVD STE B
CAPE CORAL FL
33991-3674
US

V. Phone/Fax

Practice location:
  • Phone: 239-666-4090
  • Fax:
Mailing address:
  • Phone: 239-666-4090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number StateNULL

VIII. Authorized Official

Name: DAVID RUA PEREZ
Title or Position: CEO/CO-OWNER
Credential: DMD MDS
Phone: 786-328-9108