MEDICARE: DR. CRYSTAL GILREATH RUCKER D.M.D.

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	1223P0221X	Pediatric Dentistry	DS8466	TN
2	1223P0221X	Pediatric Dentistry	8466	TN

General Provider Information

NPI Number	:	1962560631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CRYSTAL GILREATH RUCKER D.M.D.

Provider Business Mailing Address
First Line	:	7520 LORDS CHAPEL DR
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37211-7040
Country	:	US
Telephone Number	:	615-557-4442
Fax Number	:

Provider Business Practice Location Address
First Line	:	2622 MADISON ST STE G
Second Line	:
City	:	CLARKSVILLE
State	:	TN
Zip	:	37043-6555
Country	:	US
Telephone Number	:	931-919-4898
Fax Number	:	931-919-4897

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

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	10/30/2017

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