Healthcare Provider Details

I. General information

NPI: 1669781902
Provider Name (Legal Business Name): RYAN LEE CAUDILL DMD, MSD, PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2010
Last Update Date: 10/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 N SYKES CREEK PKWY SUITE 104
MERRITT ISLAND FL
32953-3492
US

IV. Provider business mailing address

270 N SYKES CREEK PKWY SUITE 104
MERRITT ISLAND FL
32953-3492
US

V. Phone/Fax

Practice location:
  • Phone: 321-453-2535
  • Fax: 321-483-3181
Mailing address:
  • Phone: 321-453-2535
  • Fax: 321-483-3181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN16680
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: