Healthcare Provider Details

I. General information

NPI: 1124363379
Provider Name (Legal Business Name): DANIEL BRUCE RUDD D.D.S, M.S.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2012
Last Update Date: 11/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 RIDGECREST DR SE STE E
RIO RANCHO NM
87124-5971
US

IV. Provider business mailing address

4320 RIDGECREST DR SE STE E
RIO RANCHO NM
87124-5971
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-1151
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD3786
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: