1013679638 NPI number — DR POLINA RHOUDENKO DMD INC

Table of content: (NPI 1013679638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013679638 NPI number — DR POLINA RHOUDENKO DMD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR POLINA RHOUDENKO DMD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1013679638
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12021 WILSHIRE BLVD STE 321
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90025-1206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-716-1783
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 LAGUNA RD STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FULLERTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92835-3633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-716-1783
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/11/2021

Additional Information

Authorized Official

Authorized Official Last Name:
RHOUDENKO
Authorized Official First Name:
POLINA
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST/PRESIDENT
Authorized Official Telephone Number:
714-716-1783

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 106839 . This is a "DENTIST" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1508448861 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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