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General NPI Number Information
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NPI Number | 1609359975
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Entity Type | Individual
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Provider Name | JACE RUTLEDGE DDS
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Gender | Male
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Dates
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Enumeration Date | 09/12/2018
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Last Update Date | 09/12/2018
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Provider Practice Location Address
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Address Line | 1700 E POINTE DR STE 300
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City | COLUMBIA
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State | MO
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Zip | 65201-6987
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Country | US
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Telephone | 573-443-1525
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Fax |
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Provider Business Mailing Address
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Address Line | 6710 PORT ORCHARD DR
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City | COLUMBIA
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State | MO
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Zip | 65203-8411
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Country | US
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Telephone | 240-437-8521
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2018033398
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License Number State | MO
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