Provider Demographics
NPI:1639543895
Name:SEACREST DENTAL SERVICES LLC
Entity Type:Organization
Organization Name:SEACREST DENTAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REESE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:850-624-9717
Mailing Address - Street 1:66 N HOLIDAY RD
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-6936
Mailing Address - Country:US
Mailing Address - Phone:850-213-2626
Mailing Address - Fax:
Practice Address - Street 1:66 N HOLIDAY RD
Practice Address - Street 2:
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-6936
Practice Address - Country:US
Practice Address - Phone:850-213-2626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-25
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN208131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty