Healthcare Provider Details

I. General information

NPI: 1902098114
Provider Name (Legal Business Name): ALYSE RUDNICKI D.D.S., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2007
Last Update Date: 08/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 OLD TAPPAN RD 2ND FLOOR
OLD TAPPAN NJ
07675-7000
US

IV. Provider business mailing address

215 OLD TAPPAN RD 2ND FLOOR
OLD TAPPAN NJ
07675-7000
US

V. Phone/Fax

Practice location:
  • Phone: 201-666-8844
  • Fax: 201-666-8811
Mailing address:
  • Phone: 201-666-8844
  • Fax: 201-666-8811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22DI02273200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: