Provider Demographics
NPI:1295040327
Name:RUDDELL ROAD DENTAL CENTER
Entity Type:Organization
Organization Name:RUDDELL ROAD DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:PERSINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-459-1600
Mailing Address - Street 1:1607 RUDDELL RD SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-2757
Mailing Address - Country:US
Mailing Address - Phone:360-459-1600
Mailing Address - Fax:
Practice Address - Street 1:1607 RUDDELL RD SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-2757
Practice Address - Country:US
Practice Address - Phone:360-459-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE601702171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1114158730OtherINDIVIDUAL NPI FOR DR. JARED D. PERSINGER, DDS