Healthcare Provider Details

I. General information

NPI: 1679738850
Provider Name (Legal Business Name): JIM EVERETT RUCKMAN JIM RUCKMAN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2008
Last Update Date: 03/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 GOODPASTURE ISLAND RD
EUGENE OR
97401-1751
US

IV. Provider business mailing address

1595 REGENCY DR
EUGENE OR
97401-7078
US

V. Phone/Fax

Practice location:
  • Phone: 541-484-0470
  • Fax:
Mailing address:
  • Phone: 541-232-7256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD9767
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: