Provider Demographics
NPI:1699668467
Name:RUCKER ORTHODONTIC SPECIALISTS A DENTAL CORP
Entity type:Organization
Organization Name:RUCKER ORTHODONTIC SPECIALISTS A DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:804-878-1069
Mailing Address - Street 1:38605 CALISTOGA DR STE 250
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-4885
Mailing Address - Country:US
Mailing Address - Phone:951-302-0685
Mailing Address - Fax:
Practice Address - Street 1:38605 CALISTOGA DR STE 250
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-4885
Practice Address - Country:US
Practice Address - Phone:951-302-0685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-31
Last Update Date:2025-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty