Provider Demographics
NPI:1700545837
Name:RUCKER, RYAN
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:RUCKER
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 1:31560 RANCHO PUEBLO RD STE 201
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-4850
Mailing Address - Country:US
Mailing Address - Phone:760-238-2563
Mailing Address - Fax:
Practice Address - Street 1:31560 RANCHO PUEBLO RD STE 201
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-4850
Practice Address - Country:US
Practice Address - Phone:951-302-0685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1060491223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty