Provider Demographics
NPI:1194803502
Name:RUTKOWSKI, RICHARD RONALD (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:RONALD
Last Name:RUTKOWSKI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2812 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-4422
Mailing Address - Country:US
Mailing Address - Phone:269-683-6331
Mailing Address - Fax:269-683-3411
Practice Address - Street 1:2812 S 11TH ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-4422
Practice Address - Country:US
Practice Address - Phone:269-683-6331
Practice Address - Fax:269-683-3411
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI109651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice