Healthcare Provider Details

I. General information

NPI: 1689646945
Provider Name (Legal Business Name): CAROLYN S RUDE D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 HAWKINS STORE ROAD SUITE A-1
KENNESAW GA
30144
US

IV. Provider business mailing address

3065 RIVER NORTH PKWY NW
ATLANTA GA
30328-1117
US

V. Phone/Fax

Practice location:
  • Phone: 770-926-3400
  • Fax:
Mailing address:
  • Phone: 770-396-7960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number8381
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: