Healthcare Provider Details

I. General information

NPI: 1760530901
Provider Name (Legal Business Name): RALPH MARK EICHSTAEDT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 W BUSCH BLVD SUITE 105
TAMPA FL
33612-7707
US

IV. Provider business mailing address

2033 20TH AVENUE PKWY
INDIAN ROCKS BEACH FL
33785-2971
US

V. Phone/Fax

Practice location:
  • Phone: 813-931-4000
  • Fax: 813-935-6532
Mailing address:
  • Phone: 407-405-4030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN15139
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: