Provider Demographics
NPI:1386729291
Name:RUPP, JEFFREY ANTHONY (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ANTHONY
Last Name:RUPP
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 1:916 W SAINT GERMAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-3424
Mailing Address - Country:US
Mailing Address - Phone:320-251-1912
Mailing Address - Fax:
Practice Address - Street 1:916 W SAINT GERMAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-3424
Practice Address - Country:US
Practice Address - Phone:320-251-1912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND94791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice