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General NPI Number Information
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NPI Number | 1366844854
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Entity Type | Organization
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Legal Business Name | SEACREST DENTAL
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Dates
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Enumeration Date | 09/16/2014
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Last Update Date | 09/16/2014
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Provider Practice Location Address
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Address Line | 5399 E COUNTY HIGHWAY 30A
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City | SANTA ROSA BEACH
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State | FL
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Zip | 32459-6717
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Country | US
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Telephone | 850-231-3736
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Fax |
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Provider Business Mailing Address
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Address Line | 5399 E COUNTY HIGHWAY 30A
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City | SANTA ROSA BEACH
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State | FL
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Zip | 32459-6717
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. FRED RUDER
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Credential |
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Telephone | 850-231-3736
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DN 20813
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License Number State | FL
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