Provider Demographics
NPI:1710681911
Name:RUDDUCK, ALANNAH BERNICE
Entity Type:Individual
Prefix:
First Name:ALANNAH
Middle Name:BERNICE
Last Name:RUDDUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALANNAH
Other - Middle Name:B
Other - Last Name:RUDDUCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:167 OLIVER HARDY CT
Mailing Address - Street 2:
Mailing Address - City:HARLEM
Mailing Address - State:GA
Mailing Address - Zip Code:30814-4535
Mailing Address - Country:US
Mailing Address - Phone:503-298-7584
Mailing Address - Fax:
Practice Address - Street 1:116 PLEASANT HOME RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-3518
Practice Address - Country:US
Practice Address - Phone:706-868-9630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADH044044124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist