Provider Demographics
NPI:1356447031
Name:RENDULICH, STEPHEN A (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:A
Last Name:RENDULICH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:9713 NORTHCROSS CENTER CT STE 100
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-7352
Mailing Address - Country:US
Mailing Address - Phone:704-875-8833
Mailing Address - Fax:704-875-0303
Practice Address - Street 1:9713 NORTHCROSS CENTER CT STE 100
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7352
Practice Address - Country:US
Practice Address - Phone:704-875-8833
Practice Address - Fax:704-875-0303
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC77491223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCU75988Medicare UPIN