Healthcare Provider Details

I. General information

NPI: 1790087138
Provider Name (Legal Business Name): ERIC R. CLAUSSEN, D.M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2010
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2624 JENKS AVE
PANAMA CITY FL
32405-4311
US

IV. Provider business mailing address

2624 JENKS AVE
PANAMA CITY FL
32405-4311
US

V. Phone/Fax

Practice location:
  • Phone: 850-215-0798
  • Fax:
Mailing address:
  • Phone: 850-215-0798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD17080
License Number StateFL

VIII. Authorized Official

Name: DR. ERIC RICHARD CLAUSSEN
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 407-408-4880