Healthcare Provider Details

I. General information

NPI: 1487682720
Provider Name (Legal Business Name): MATTHEW SETH RUDOLPH D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2696 OLIVIA HEIGHTS AVE
HENDERSON NV
89052-7039
US

IV. Provider business mailing address

2696 OLIVIA HEIGHTS AVE
HENDERSON NV
89052-7039
US

V. Phone/Fax

Practice location:
  • Phone: 901-289-2494
  • Fax:
Mailing address:
  • Phone: 901-289-2494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS030358L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: