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General NPI Number Information
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NPI Number | 1174803340
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Entity Type | Individual
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Provider Name | RONALD GENE LIST DENTIST
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Gender | Male
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Dates
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Enumeration Date | 08/19/2011
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Last Update Date | 08/19/2011
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Provider Practice Location Address
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Address Line | 1460 BAYTREE DR NE
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City | PALM BAY
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State | FL
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Zip | 32905-3900
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Country | US
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Telephone | 321-914-0915
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Fax | 321-914-0916
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Provider Business Mailing Address
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Address Line | 1460 BAYTREE DR
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City | PALM BAY
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State | FL
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Zip | 32905
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Country | US
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Telephone | 321-914-0915
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Fax | 321-914-0916
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN19390
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License Number State | FL
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