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General NPI Number Information
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NPI Number | 1912321654
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Entity Type | Organization
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Legal Business Name | EDWARD L. STAUDT DDS & KENNETH L. STAUDT DDS, MPH
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Dates
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Enumeration Date | 02/18/2014
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Last Update Date | 02/20/2014
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Provider Practice Location Address
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Address Line | 944 BRIDGEWATER DR. SUITE 2-B
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City | PORT ORANGE
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State | FL
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Zip | 32129
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Country | US
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Telephone | 386-756-8953
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Fax |
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Provider Business Mailing Address
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Address Line | 944 BRIDGEWATER DR. SUITE 2-B
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City | PORT ORANGE
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State | FL
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Zip | 32129
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Country | US
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Telephone | 386-756-8953
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Fax | 386-756-9184
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Authorized Official
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Title or Position | DENTIST
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Name | DR. KENNETH LEE STAUDT JR.
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Credential | DDS, MPH
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Telephone | 386-214-7554
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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 | DN9915
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN11886
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License Number State | FL
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