Provider Demographics
NPI:1033482260
Name:RUDOLPH, GLENN (DMD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 STRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1432
Mailing Address - Country:US
Mailing Address - Phone:256-762-8908
Mailing Address - Fax:
Practice Address - Street 1:3707 CHAMBERLAIN LN
Practice Address - Street 2:SUITE 103
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2001
Practice Address - Country:US
Practice Address - Phone:502-412-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-19
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6014122300000X
KY9731122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist