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General NPI Number Information
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NPI Number | 1538591706
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Entity Type | Organization
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Legal Business Name | SEACREST DENTAL II LLC
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Dates
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Enumeration Date | 07/30/2013
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Last Update Date | 05/21/2014
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Provider Practice Location Address
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Address Line | 66 N HOLIDAY RD
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City | MIRAMAR BEACH
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State | FL
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Zip | 32550-6936
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Country | US
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Telephone | 850-231-3736
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Fax | 888-654-4326
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Provider Business Mailing Address
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Address Line | 5399 E COUNTY HIGHWAY 30A SUITE 1
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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 | 888-654-4326
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Authorized Official
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Title or Position | CO-OWNER
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Name | DR. FRED EDWIN RUDER
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Credential | DDS
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN10145
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License Number State | FL
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