Provider Demographics
NPI:1730305905
Name:RUDOLPH, MICHAEL LAWRENCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:RUDOLPH
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 1:2104 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3704
Mailing Address - Country:US
Mailing Address - Phone:574-269-1787
Mailing Address - Fax:574-267-1610
Practice Address - Street 1:2104 E CENTER ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3704
Practice Address - Country:US
Practice Address - Phone:574-269-1787
Practice Address - Fax:574-267-1610
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010923A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist