Healthcare Provider Details

I. General information

NPI: 1578408209
Provider Name (Legal Business Name): CHASE RUCKHABER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12050 VENTURA BLVD STE C101
STUDIO CITY CA
91604-2639
US

IV. Provider business mailing address

14116 VALLEY VISTA BLVD
SHERMAN OAKS CA
91423-4657
US

V. Phone/Fax

Practice location:
  • Phone: 818-296-9142
  • Fax:
Mailing address:
  • Phone: 248-996-7207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number111822
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: