Provider Demographics
NPI:1144887852
Name:PRUITT, PATRICK
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:PRUITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4232 E COUNTY ROAD 466 STE 101
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:FL
Mailing Address - Zip Code:34484-3544
Mailing Address - Country:US
Mailing Address - Phone:352-461-0830
Mailing Address - Fax:
Practice Address - Street 1:4232 E COUNTY ROAD 466 STE 101
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:FL
Practice Address - Zip Code:34484-3544
Practice Address - Country:US
Practice Address - Phone:352-461-0830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24111122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist