Provider Demographics
NPI:1093250151
Name:RUCKMAN ORAL SURGERY & IMPLANT CENTER
Entity Type:Organization
Organization Name:RUCKMAN ORAL SURGERY & IMPLANT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WISSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-489-0001
Mailing Address - Street 1:9901 AUBURN RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2345
Mailing Address - Country:US
Mailing Address - Phone:260-489-0001
Mailing Address - Fax:260-489-0004
Practice Address - Street 1:9901 AUBURN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2345
Practice Address - Country:US
Practice Address - Phone:260-489-0001
Practice Address - Fax:260-489-0004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-28
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty