Provider Demographics
NPI:1609359975
Name:RUTLEDGE, JACE (DDS)
Entity Type:Individual
Prefix:
First Name:JACE
Middle Name:
Last Name:RUTLEDGE
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 1:6710 PORT ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-8411
Mailing Address - Country:US
Mailing Address - Phone:240-437-8521
Mailing Address - Fax:
Practice Address - Street 1:1700 E POINTE DR STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6987
Practice Address - Country:US
Practice Address - Phone:573-443-1525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180333981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice