Healthcare Provider Details

I. General information

NPI: 1013077403
Provider Name (Legal Business Name): RANOLPH DUANE RUSH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3536 MENDOCINO AVE SUITE #330
SANTA ROSA CA
95403-3634
US

IV. Provider business mailing address

3536 MENDOCINO AVENUE #330
SANTA ROSA CA
95403-3634
US

V. Phone/Fax

Practice location:
  • Phone: 707-545-4104
  • Fax: 707-545-9668
Mailing address:
  • Phone: 707-545-4104
  • Fax: 707-545-9668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number23239
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: