Provider Demographics
NPI:1073252771
Name:RYDSTROM, ROBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:RYDSTROM
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 1:15 HOLLISTER LN
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-4003
Mailing Address - Country:US
Mailing Address - Phone:631-664-2930
Mailing Address - Fax:
Practice Address - Street 1:150 55TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-2508
Practice Address - Country:US
Practice Address - Phone:718-630-7942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program