Provider Demographics
NPI:1033210943
Name:RUFFIN, WYATT M JR (DDS)
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:M
Last Name:RUFFIN
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3940 AIRLINE BLVD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-3329
Mailing Address - Country:US
Mailing Address - Phone:757-465-4884
Mailing Address - Fax:757-465-4884
Practice Address - Street 1:3940 AIRLINE BLVD
Practice Address - Street 2:SUITE 114
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-3329
Practice Address - Country:US
Practice Address - Phone:757-465-4884
Practice Address - Fax:757-465-4884
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401006433122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7821743Medicaid