Provider Demographics
NPI:1073602645
Name:RUDD, JEREMY I (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:I
Last Name:RUDD
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 1:1750 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3400
Mailing Address - Country:US
Mailing Address - Phone:817-473-6857
Mailing Address - Fax:817-473-6256
Practice Address - Street 1:1750 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3400
Practice Address - Country:US
Practice Address - Phone:817-473-6857
Practice Address - Fax:817-473-6256
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX224861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice