Provider Demographics
NPI:1578959375
Name:RONALD L RUMBAUGH DDS PC
Entity Type:Organization
Organization Name:RONALD L RUMBAUGH DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:RUMBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-637-6976
Mailing Address - Street 1:10506 COLDWATER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1235
Mailing Address - Country:US
Mailing Address - Phone:260-637-6976
Mailing Address - Fax:260-637-6976
Practice Address - Street 1:10506 COLDWATER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1235
Practice Address - Country:US
Practice Address - Phone:260-637-6976
Practice Address - Fax:260-637-6976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008140A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100055440AMedicaid