Basic Information
| Provider Information | |||||||||
| NPI: | 1306395280 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNITED STATES NAVY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 853 VALLEY AVE | ||||||||
| Address2: | |||||||||
| City: | SOLANA BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920752492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319483006 | ||||||||
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| Practice Location | |||||||||
| Address1: | BUILDING H 2005 KNIGHT LANE | ||||||||
| Address2: | NAVY MEDICINE SUPPORT COMMAND ATTN: MEDICAL STAFF SVCS | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322120140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607253213 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2016 | ||||||||
| LastUpdateDate: | 10/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | RUOCCO | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | COMMANDING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7607255208 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 7136-15 | WI | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.