Provider Demographics
NPI:1912321654
Name:EDWARD L. STAUDT DDS & KENNETH L. STAUDT DDS, MPH
Entity Type:Organization
Organization Name:EDWARD L. STAUDT DDS & KENNETH L. STAUDT DDS, MPH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:STAUDT
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS, MPH
Authorized Official - Phone:386-214-7554
Mailing Address - Street 1:944 BRIDGEWATER DR.
Mailing Address - Street 2:SUITE 2-B
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129
Mailing Address - Country:US
Mailing Address - Phone:386-756-8953
Mailing Address - Fax:386-756-9184
Practice Address - Street 1:944 BRIDGEWATER DR.
Practice Address - Street 2:SUITE 2-B
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129
Practice Address - Country:US
Practice Address - Phone:386-756-8953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDWARD L. STAUDT DDS & KENNETH L. STAUDT DDS, MPH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-18
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN118861223G0001X
FLDN99151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty