Provider Demographics
NPI:1457649824
Name:RUDOLPH, EDWARD
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 W 187TH ST
Mailing Address - Street 2:APT 4H
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-1513
Mailing Address - Country:US
Mailing Address - Phone:551-486-2899
Mailing Address - Fax:
Practice Address - Street 1:728 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW SQUARE
Practice Address - State:NY
Practice Address - Zip Code:10977-8916
Practice Address - Country:US
Practice Address - Phone:845-354-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056060-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice