Healthcare Provider Details

I. General information

NPI: 1649312158
Provider Name (Legal Business Name): VAL L KUDRYK D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 CLEARWATER DR SUITE A
PRESCOTT AZ
86305-7165
US

IV. Provider business mailing address

190 MISTY MEADOW CIR
PRESCOTT AZ
86303-5819
US

V. Phone/Fax

Practice location:
  • Phone: 928-443-0955
  • Fax: 928-443-0931
Mailing address:
  • Phone: 928-443-9151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD6792
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: