Provider Demographics
NPI:1710057096
Name:RUISCH, RANDALL JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:JAMES
Last Name:RUISCH
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 1:5965 DOGWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-1633
Mailing Address - Country:US
Mailing Address - Phone:515-276-0723
Mailing Address - Fax:
Practice Address - Street 1:1000 73RD ST., STE 1
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50311
Practice Address - Country:US
Practice Address - Phone:515-223-5001
Practice Address - Fax:515-327-6282
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA60471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0079053Medicaid