MEDICARE: DR. JEFFREY ANTHONY RUPP DDS

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	1223G0001X	General Practice Dentistry	D9479	MN

General Provider Information

NPI Number	:	1386729291
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY ANTHONY RUPP DDS

Provider Business Mailing Address
First Line	:	916 W SAINT GERMAIN ST
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-3424
Country	:	US
Telephone Number	:	320-251-1912
Fax Number	:

Provider Business Practice Location Address
First Line	:	916 W SAINT GERMAIN ST
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-3424
Country	:	US
Telephone Number	:	320-251-1912
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	07/08/2007

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