Provider Demographics
NPI:1801080916
Name:RUFFATTO, KARA MARIE (DMD)
Entity type:Individual
Prefix:DR
First Name:KARA
Middle Name:MARIE
Last Name:RUFFATTO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:KARA
Other - Middle Name:MARIE
Other - Last Name:VAN HISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:201 W KENYON RD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7892
Mailing Address - Country:US
Mailing Address - Phone:217-531-4279
Mailing Address - Fax:217-531-4333
Practice Address - Street 1:201 W KENYON RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7892
Practice Address - Country:US
Practice Address - Phone:217-531-4279
Practice Address - Fax:217-531-4333
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027446122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019027446Medicaid