1457403917 NPI number — DR. SARA BETH RUDOLPH D.D.S.

Table of content: DR. SARA BETH RUDOLPH D.D.S. (NPI 1457403917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457403917 NPI number — DR. SARA BETH RUDOLPH D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUDOLPH
Provider First Name:
SARA
Provider Middle Name:
BETH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457403917
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3539 S STERLING CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85297-4942
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-430-7272
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21321 E OCOTILLO RD
Provider Second Line Business Practice Location Address:
BUILDING E SUITE 112
Provider Business Practice Location Address City Name:
QUEEN CREEK
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85142-5996
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-882-9710
Provider Business Practice Location Address Fax Number:
480-882-9706
Provider Enumeration Date:
01/17/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  019026167 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: D009520 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)