Healthcare Provider Details

I. General information

NPI: 1205870169
Provider Name (Legal Business Name): WILLIE J RUCKER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16048 KEDZIE AVENUE
MARKHAM IL
60428
US

IV. Provider business mailing address

PO BOX 0278 16048 KEDZIE AVENUE
MARKHAM IL
60428
US

V. Phone/Fax

Practice location:
  • Phone: 708-331-4999
  • Fax: 708-331-5043
Mailing address:
  • Phone: 708-331-4999
  • Fax: 708-331-5043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12009827B
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: