Healthcare Provider Details

I. General information

NPI: 1700545837
Provider Name (Legal Business Name): DR. RYAN RUCKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2021
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31560 RANCHO PUEBLO RD STE 201
TEMECULA CA
92592-4850
US

IV. Provider business mailing address

31560 RANCHO PUEBLO RD STE 201
TEMECULA CA
92592-4850
US

V. Phone/Fax

Practice location:
  • Phone: 951-302-0685
  • Fax:
Mailing address:
  • Phone: 760-238-2563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number106049
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: