Healthcare Provider Details

I. General information

NPI: 1922019330
Provider Name (Legal Business Name): CARL RUDERMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6309 BALTIMORE AVENUE #202
RIVERDALE MD
20737-1022
US

IV. Provider business mailing address

6309 BALTIMORE AVENUE #202
RIVERDALE MD
20737-1022
US

V. Phone/Fax

Practice location:
  • Phone: 301-864-6535
  • Fax: 301-864-8093
Mailing address:
  • Phone: 301-864-6535
  • Fax: 301-864-8093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6827
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: