Provider Demographics
NPI:1659636785
Name:RUGGLESS, SHANE (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:RUGGLESS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IL
Mailing Address - Zip Code:62615-9787
Mailing Address - Country:US
Mailing Address - Phone:217-438-3721
Mailing Address - Fax:
Practice Address - Street 1:500 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IL
Practice Address - Zip Code:62615-9787
Practice Address - Country:US
Practice Address - Phone:217-438-3721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-04
Last Update Date:2012-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0290241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice