| Organization Name: | SEACREST DENTAL |
| NPI Number: | 1366844854 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | FRED RUDER (OWNER) |
| Mailing Address: | 5399 E County Highway 30a Santa Rosa Beach |
| State: | FL US |
| Postal Code: | 324596717 |
| Phone Number: | 8502313736 |
| Fax Number: | |
| NPI Enumeration Date: | 09/16/2014 |
| NPI Last Update Date: | 09/16/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | DN 20813 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |