Provider Demographics
NPI:1912524596
Name:DUDOVITZ, ROXANNE
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:DUDOVITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2941 HIGHWAY K
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-7862
Mailing Address - Country:US
Mailing Address - Phone:636-272-7009
Mailing Address - Fax:
Practice Address - Street 1:2941 HIGHWAY K
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-7862
Practice Address - Country:US
Practice Address - Phone:636-272-7009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020018228122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist