Healthcare Provider Details

I. General information

NPI: 1336333780
Provider Name (Legal Business Name): RALPH B WAUGH DDS MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 S GOLD CANYON
RIDGECREST CA
93555
US

IV. Provider business mailing address

119 S GOLD CANYON
RIDGECREST CA
93555
US

V. Phone/Fax

Practice location:
  • Phone: 760-375-1511
  • Fax: 760-375-5980
Mailing address:
  • Phone: 760-375-1511
  • Fax: 760-375-5980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA22524
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number14900
License Number StateCA

VIII. Authorized Official

Name: MR. RALPH B WAUGH
Title or Position: PRESIDENT OF CORPORATION
Credential: DDS MD
Phone: 661-948-5061