Healthcare Provider Details

I. General information

NPI: 1033105986
Provider Name (Legal Business Name): JOSE F EDUARDO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1381 S PATRICK DR 45TH MEDICAL GROUP
PATRICK AFB FL
32925
US

IV. Provider business mailing address

1907 AUBURN LAKES DR
ROCKLEDGE FL
32955
US

V. Phone/Fax

Practice location:
  • Phone: 321-494-6366
  • Fax: 321-494-1378
Mailing address:
  • Phone: 321-636-3177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN15816
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: