MEDICARE: RUCKMAN ORAL SURGERY & IMPLANT CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1093250151
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUCKMAN ORAL SURGERY & IMPLANT CENTER

Provider Business Mailing Address
First Line	:	9901 AUBURN RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-2345
Country	:	US
Telephone Number	:	260-489-0001
Fax Number	:	260-489-0004

Provider Business Practice Location Address
First Line	:	9901 AUBURN RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-2345
Country	:	US
Telephone Number	:	260-489-0001
Fax Number	:	260-489-0004

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	GABRIELLE WISSMAN
Credential	:
Telephone Number	:	260-489-0001

Provider Enumeration Date	:	12/28/2016
Last Update Date	:	02/22/2022

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