Provider Demographics
NPI:1679029904
Name:RURAK, EVAN LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:LEE
Last Name:RURAK
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 1:1305 RODMAN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3916
Mailing Address - Country:US
Mailing Address - Phone:757-397-3296
Mailing Address - Fax:
Practice Address - Street 1:1305 RODMAN AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3916
Practice Address - Country:US
Practice Address - Phone:757-397-3296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401416089122300000X
UT9838416-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist