MEDICARE: DR. PHIL NOBLE RUCKMAN III 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	12011439A	IN

General Provider Information

NPI Number	:	1861711244
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHIL NOBLE RUCKMAN III D.D.S.

Provider Business Mailing Address
First Line	:	10708 TRADE WIND CT
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-2662
Country	:	US
Telephone Number	:	260-750-7825
Fax Number	:

Provider Business Practice Location Address
First Line	:	6405 GEORGETOWN NORTH BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7007
Country	:	US
Telephone Number	:	260-485-0583
Fax Number	:

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

Provider Enumeration Date	:	05/24/2010
Last Update Date	:	05/24/2010

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