MEDICARE: DR. DWIGHT ANTONIO RUDDOCK D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	14888	TX

General Provider Information

NPI Number	:	1275546780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DWIGHT ANTONIO RUDDOCK D.D.S

Provider Business Mailing Address
First Line	:	719 HEMPHILL ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3106
Country	:	US
Telephone Number	:	817-335-3806
Fax Number	:	817-338-1681

Provider Business Practice Location Address
First Line	:	719 HEMPHILL ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3106
Country	:	US
Telephone Number	:	817-335-3806
Fax Number	:	817-338-1681

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	07/08/2007

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