Provider Demographics
NPI:1326072802
Name:RUTHERFORD, J GLENN (DDS)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:GLENN
Last Name:RUTHERFORD
Suffix:
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 1:900 BLACK POWDER PL
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-9375
Mailing Address - Country:US
Mailing Address - Phone:970-731-5983
Mailing Address - Fax:
Practice Address - Street 1:51 DAVID DR
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-9440
Practice Address - Country:US
Practice Address - Phone:970-731-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO60651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04014924Medicaid