Provider Demographics
NPI:1336145622
Name:FUDGE, STEVEN RALPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:RALPH
Last Name:FUDGE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4913 HARROUN RD
Mailing Address - Street 2:STE 2
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2102
Mailing Address - Country:US
Mailing Address - Phone:419-882-6896
Mailing Address - Fax:419-882-3162
Practice Address - Street 1:4913 HARROUN RD
Practice Address - Street 2:STE 2
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2102
Practice Address - Country:US
Practice Address - Phone:419-882-6896
Practice Address - Fax:419-882-3162
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH160591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice