Provider Demographics
NPI:1912547811
Name:CINCY PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:CINCY PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:513-400-8551
Mailing Address - Street 1:1131 CRYER AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45208
Mailing Address - Country:US
Mailing Address - Phone:513-400-8551
Mailing Address - Fax:
Practice Address - Street 1:7777 YANKEE RD
Practice Address - Street 2:
Practice Address - City:LIBERTY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45044-3500
Practice Address - Country:US
Practice Address - Phone:937-245-0390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-09
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty