Healthcare Provider Details

I. General information

NPI: 1497317242
Provider Name (Legal Business Name): NERY RUANO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5445 S WILLIAMSON BLVD
PORT ORANGE FL
32128-7399
US

IV. Provider business mailing address

5445 S WILLIAMSON BLVD
PORT ORANGE FL
32128-7399
US

V. Phone/Fax

Practice location:
  • Phone: 386-947-7211
  • Fax:
Mailing address:
  • Phone: 386-947-7211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN24379
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: