Provider Demographics
NPI:1790219384
Name:RUDNICKI, OLIVIA
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:RUDNICKI
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 1:710 FRANKLIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-3564
Mailing Address - Country:US
Mailing Address - Phone:219-872-6200
Mailing Address - Fax:219-879-2915
Practice Address - Street 1:710 FRANKLIN ST STE 200
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360
Practice Address - Country:US
Practice Address - Phone:219-872-6200
Practice Address - Fax:219-879-2915
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012921A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist