Healthcare Provider Details

I. General information

NPI: 1316218977
Provider Name (Legal Business Name): FRED LOUIS RUDMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2012
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 E MAIN ST
MIDDLETOWN MD
21769-7722
US

IV. Provider business mailing address

11643 MEETING HOUSE RD
MYERSVILLE MD
21773-8905
US

V. Phone/Fax

Practice location:
  • Phone: 301-293-6828
  • Fax: 301-371-4989
Mailing address:
  • Phone: 301-293-6828
  • Fax: 301-371-4989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7537
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: