Provider Demographics
NPI:1518026426
Name:WOODLANDS VILLAGE DENTISTRY PC
Entity Type:Organization
Organization Name:WOODLANDS VILLAGE DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:RUGE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-774-5599
Mailing Address - Street 1:1120 W UNIVERSITY AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001
Mailing Address - Country:US
Mailing Address - Phone:928-774-5599
Mailing Address - Fax:928-773-0257
Practice Address - Street 1:1120 W UNIVERSITY AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-774-5599
Practice Address - Fax:928-773-0257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3157122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1144227745Medicare UPIN