=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518026426
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOODLANDS VILLAGE DENTISTRY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1120 W UNIVERSITY AVE SUITE 103
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-774-5599
-----------------------------------------------------
Fax | 928-773-0257
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1120 W UNIVERSITY AVE SUITE 103
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-774-5599
-----------------------------------------------------
Fax | 928-773-0257
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT DENTIST
-----------------------------------------------------
Name | DR. ROBERT W RUGE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 928-774-5599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 3157
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------