Provider Demographics
NPI:1659895001
Name:RUTHERFORD, DYLAN W (DDS)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:W
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 1:2110 E RUSK ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-9052
Mailing Address - Country:US
Mailing Address - Phone:903-586-0741
Mailing Address - Fax:903-586-0649
Practice Address - Street 1:2110 E RUSK ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-9052
Practice Address - Country:US
Practice Address - Phone:903-586-0741
Practice Address - Fax:903-586-0649
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33329122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist