Provider Demographics
NPI:1477096667
Name:RUDELICH, LUCAS JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LUCAS
Middle Name:JOHN
Last Name:RUDELICH
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 1:5255 S 4015 W
Mailing Address - Street 2:SUITE #180
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84129-4257
Mailing Address - Country:US
Mailing Address - Phone:801-968-9003
Mailing Address - Fax:801-968-9069
Practice Address - Street 1:5255 S 4015 W
Practice Address - Street 2:SUITE #180
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129-4257
Practice Address - Country:US
Practice Address - Phone:801-968-9003
Practice Address - Fax:801-968-9069
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10165628-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist