Provider Demographics
NPI:1174803340
Name:LIST, RONALD GENE (DENTIST)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:GENE
Last Name:LIST
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 BAYTREE DR
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905
Mailing Address - Country:US
Mailing Address - Phone:321-914-0915
Mailing Address - Fax:321-914-0916
Practice Address - Street 1:1460 BAYTREE DR NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-3900
Practice Address - Country:US
Practice Address - Phone:321-914-0915
Practice Address - Fax:321-914-0916
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19390122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist