Provider Demographics
NPI:1679643001
Name:RADULOVICH, RAD S (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAD
Middle Name:S
Last Name:RADULOVICH
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 1:10920 VENICE BLVD
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-3809
Mailing Address - Country:US
Mailing Address - Phone:310-204-6661
Mailing Address - Fax:310-204-6662
Practice Address - Street 1:10920 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-3809
Practice Address - Country:US
Practice Address - Phone:310-204-6661
Practice Address - Fax:310-204-6662
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA445311223G0001X
NV4553T1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB44531-01Medicaid