Provider Demographics
NPI:1972971125
Name:THOMAS O RUDERSDORF LLC
Entity Type:Organization
Organization Name:THOMAS O RUDERSDORF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:O
Authorized Official - Last Name:RUDERSDORF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-292-1200
Mailing Address - Street 1:11513 S 37TH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-5210
Mailing Address - Country:US
Mailing Address - Phone:402-292-1200
Mailing Address - Fax:
Practice Address - Street 1:11513 S 37TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68123-5210
Practice Address - Country:US
Practice Address - Phone:402-292-1200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6609122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty