Healthcare Provider Details

I. General information

NPI: 1790219384
Provider Name (Legal Business Name): OLIVIA RUDNICKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2017
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 FRANKLIN ST STE 200
MICHIGAN CITY IN
46360
US

IV. Provider business mailing address

710 FRANKLIN ST STE 200
MICHIGAN CITY IN
46360-3564
US

V. Phone/Fax

Practice location:
  • Phone: 219-872-6200
  • Fax: 219-879-2915
Mailing address:
  • Phone: 219-872-6200
  • Fax: 219-879-2915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12012921A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: