Healthcare Provider Details

I. General information

NPI: 1679691042
Provider Name (Legal Business Name): JOHN KELLY RUGELEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8240 N MO PAC EXPY SUITE 285
AUSTIN TX
78759-8840
US

IV. Provider business mailing address

8240 N MO PAC EXPY SUITE 285
AUSTIN TX
78759-8840
US

V. Phone/Fax

Practice location:
  • Phone: 512-343-2758
  • Fax: 512-343-2941
Mailing address:
  • Phone: 512-343-2758
  • Fax: 512-343-2941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number15947
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: