Provider Demographics
NPI:1063610269
Name:J. GLENN RUTHERFORD DDS PC
Entity type:Organization
Organization Name:J. GLENN RUTHERFORD DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-731-3627
Mailing Address - Street 1:51 DAVID DR
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-9440
Mailing Address - Country:US
Mailing Address - Phone:970-731-3627
Mailing Address - Fax:970-731-2395
Practice Address - Street 1:51 DAVID DR
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-9440
Practice Address - Country:US
Practice Address - Phone:970-731-3627
Practice Address - Fax:970-731-2395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO60651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04014924Medicaid