Healthcare Provider Details

I. General information

NPI: 1194554535
Provider Name (Legal Business Name): ALEX JOSEPH LIBOON RUSTIA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 01/26/2026
Certification Date: 01/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MALAGA ST
ST AUGUSTINE FL
32084-3521
US

IV. Provider business mailing address

278 TIDAL BEACH AVE
ST AUGUSTINE FL
32095-0148
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-9024
  • Fax:
Mailing address:
  • Phone: 908-670-6108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN29444
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: