Provider Demographics
NPI:1659711638
Name:KURUDIMOVA, TATIANA
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:KURUDIMOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 CHARLOTTE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2701 W 10TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19013-1936
Practice Address - Country:US
Practice Address - Phone:610-364-0404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0395581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice