Provider Demographics
NPI:1073722633
Name:RUDIN, JONATHAN (DDS, MS, MPH)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:RUDIN
Suffix:
Gender:M
Credentials:DDS, MS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5471 CAMINITO EXQUISITO
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5471 CAMINITO EXQUISITO
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2825
Practice Address - Country:US
Practice Address - Phone:858-792-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA496541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice