Provider Demographics
NPI:1821677964
Name:RUDISILL, EDWARD TUCKER (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:TUCKER
Last Name:RUDISILL
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 1:1030 N COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-2288
Mailing Address - Country:US
Mailing Address - Phone:501-701-0539
Mailing Address - Fax:
Practice Address - Street 1:1030 N COLORADO ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-2288
Practice Address - Country:US
Practice Address - Phone:501-701-0539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7215122300000X
390200000X
AZD011952122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program