Provider Demographics
NPI:1023476363
Name:RUCK TRONCOSO, PABLO MARTIN
Entity type:Individual
Prefix:
First Name:PABLO
Middle Name:MARTIN
Last Name:RUCK TRONCOSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15386 GUNSMITH TER
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3928
Mailing Address - Country:US
Mailing Address - Phone:571-338-3907
Mailing Address - Fax:
Practice Address - Street 1:4379 RIDGEWOOD CENTER DR STE 102
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-8323
Practice Address - Country:US
Practice Address - Phone:703-680-7950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-01
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014157251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice