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General NPI Number Information
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NPI Number | 1194554535
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Entity Type | Individual
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Provider Name | ALEX JOSEPH LIBOON RUSTIA DMD
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Gender | Male
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Dates
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Enumeration Date | 08/01/2024
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Last Update Date | 01/26/2026
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Provider Practice Location Address
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Address Line | 150 MALAGA ST
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City | ST AUGUSTINE
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State | FL
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Zip | 32084-3521
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Country | US
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Telephone | 904-829-9024
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Fax |
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Provider Business Mailing Address
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Address Line | 278 TIDAL BEACH AVE
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City | ST AUGUSTINE
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State | FL
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Zip | 32095-0148
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Country | US
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Telephone | 908-670-6108
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Fax |
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN29444
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License Number State | FL
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