Provider Demographics
NPI:1881694560
Name:RUDUSKY, BRYAN MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:MICHAEL
Last Name:RUDUSKY
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:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:WELLS
Mailing Address - State:ME
Mailing Address - Zip Code:04090-0497
Mailing Address - Country:US
Mailing Address - Phone:207-646-2520
Mailing Address - Fax:207-646-2540
Practice Address - Street 1:1662 US RR 1
Practice Address - Street 2:
Practice Address - City:WELLS
Practice Address - State:ME
Practice Address - Zip Code:04090-0497
Practice Address - Country:US
Practice Address - Phone:207-646-2520
Practice Address - Fax:207-646-2540
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3612122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
039863OtherANTHEM
Z89511OtherANTHEM BLUE CROSS