Healthcare Provider Details

I. General information

NPI: 1629136775
Provider Name (Legal Business Name): DENNIS ANDREW KUACK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2644 S RIDGEWOOD AVE
SOUTH DAYTONA FL
32119
US

IV. Provider business mailing address

2644 S RIDGEWOOD AVE
SOUTH DAYTONA FL
32119
US

V. Phone/Fax

Practice location:
  • Phone: 386-761-5883
  • Fax:
Mailing address:
  • Phone: 386-761-5883
  • Fax: 386-761-6159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7177
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: