Provider Demographics
NPI:1194554535
Name:RUSTIA, ALEX JOSEPH LIBOON (DMD)
Entity type:Individual
Prefix:DR
First Name:ALEX JOSEPH
Middle Name:LIBOON
Last Name:RUSTIA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 CROSS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-8445
Mailing Address - Country:US
Mailing Address - Phone:908-670-6108
Mailing Address - Fax:
Practice Address - Street 1:7451 103RD ST STE 18
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-6789
Practice Address - Country:US
Practice Address - Phone:904-777-4622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN294441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice