Healthcare Provider Details

I. General information

NPI: 1568841955
Provider Name (Legal Business Name): EMILY SCHROEDER RUTSIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FORTENBERRY RD
MERRITT ISLAND FL
32952-3617
US

IV. Provider business mailing address

100 FORTENBERRY RD
MERRITT ISLAND FL
32952-3617
US

V. Phone/Fax

Practice location:
  • Phone: 321-459-2022
  • Fax: 877-832-5061
Mailing address:
  • Phone: 321-459-2022
  • Fax: 877-832-5061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN21603
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: