Provider Demographics
NPI:1336389931
Name:ROCKLEDGE DENTAL PA
Entity Type:Organization
Organization Name:ROCKLEDGE DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-726-1611
Mailing Address - Street 1:1950 ROCKLEDGE BLVD
Mailing Address - Street 2:207
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3763
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1950 ROCKLEDGE BLVD
Practice Address - Street 2:207
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3763
Practice Address - Country:US
Practice Address - Phone:321-632-1820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty