Provider Demographics
NPI:1962560631
Name:RUCKER, CRYSTAL GILREATH (DMD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:GILREATH
Last Name:RUCKER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7520 LORDS CHAPEL DR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-7040
Mailing Address - Country:US
Mailing Address - Phone:615-557-4442
Mailing Address - Fax:
Practice Address - Street 1:2622 MADISON ST STE G
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-6555
Practice Address - Country:US
Practice Address - Phone:931-919-4898
Practice Address - Fax:931-919-4897
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS84661223P0221X
TN84661223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty