Provider Demographics
NPI:1336920016
Name:DOVETAIL ORTHOPEDICS, LLC
Entity type:Organization
Organization Name:DOVETAIL ORTHOPEDICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:SANTROCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-216-7960
Mailing Address - Street 1:2416 LYNNDALE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-5201
Mailing Address - Country:US
Mailing Address - Phone:904-430-7132
Mailing Address - Fax:904-601-1512
Practice Address - Street 1:2416 LYNNDALE RD STE 102
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-5201
Practice Address - Country:US
Practice Address - Phone:904-430-7132
Practice Address - Fax:904-601-1512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Single Specialty