Provider Demographics
NPI:1992853360
Name:ROMAN, RUDOLPH E (DMD)
Entity Type:Individual
Prefix:DR
First Name:RUDOLPH
Middle Name:E
Last Name:ROMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13642 GROSSE PT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-4762
Mailing Address - Country:US
Mailing Address - Phone:619-449-6009
Mailing Address - Fax:619-449-1460
Practice Address - Street 1:9510 CUYAMACA ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-2686
Practice Address - Country:US
Practice Address - Phone:619-449-6009
Practice Address - Fax:619-449-1460
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA426971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice