Healthcare Provider Details

I. General information

NPI: 1255486601
Provider Name (Legal Business Name): LINDY D RUCKS D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5775 BRITTANY FORREST LN
SAN DIEGO CA
92130-4828
US

IV. Provider business mailing address

5775 BRITTANY FORREST LN
SAN DIEGO CA
92130-4828
US

V. Phone/Fax

Practice location:
  • Phone: 847-624-1121
  • Fax:
Mailing address:
  • Phone: 847-624-1121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number100558
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019026717
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: