Provider Demographics
NPI:1851517676
Name:RUDOLPH, CARMON R (DMD)
Entity Type:Individual
Prefix:
First Name:CARMON
Middle Name:R
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6708 HARRODS VIEW CIR
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-9473
Mailing Address - Country:US
Mailing Address - Phone:502-228-3068
Mailing Address - Fax:
Practice Address - Street 1:139 SAINT MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3117
Practice Address - Country:US
Practice Address - Phone:502-895-3774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY57501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice