Provider Demographics
NPI:1174493969
Name:STAUDT DENTAL, LLC
Entity type:Organization
Organization Name:STAUDT DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:STAUDT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:386-756-8953
Mailing Address - Street 1:944 BRIDGEWATER DR STE 2B
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-6110
Mailing Address - Country:US
Mailing Address - Phone:386-756-8953
Mailing Address - Fax:
Practice Address - Street 1:275 WILLIAMSON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5997
Practice Address - Country:US
Practice Address - Phone:386-756-8953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-11-07
Last Update Date:2025-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental