Provider Demographics
NPI:1184838112
Name:RUDOLPH, LAWRENCE (DMD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
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 1:1165 MCKINNEY LN
Mailing Address - Street 2:SUITE #1006
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15220-3417
Mailing Address - Country:US
Mailing Address - Phone:412-937-9070
Mailing Address - Fax:
Practice Address - Street 1:1165 MCKINNEY LN
Practice Address - Street 2:SUITE #1006
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15220-3417
Practice Address - Country:US
Practice Address - Phone:412-937-9070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS021586L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA520709OtherUNITED CONCORDIA ID #