Provider Demographics
NPI:1316104987
Name:RONNEBURG, RICHARD JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JAMES
Last Name:RONNEBURG
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 1:103 S FOREST RD
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-4895
Mailing Address - Country:US
Mailing Address - Phone:209-532-3644
Mailing Address - Fax:209-532-4251
Practice Address - Street 1:103 S FOREST RD
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-4895
Practice Address - Country:US
Practice Address - Phone:209-532-3644
Practice Address - Fax:209-532-4251
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA504171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice