Healthcare Provider Details

I. General information

NPI: 1992760789
Provider Name (Legal Business Name): RUDOLPH JOHN BRAYDICH JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 E LIBERTY ST
HUBBARD OH
44425-2160
US

IV. Provider business mailing address

45 E LIBERTY ST
HUBBARD OH
44425-2160
US

V. Phone/Fax

Practice location:
  • Phone: 330-534-5408
  • Fax: 330-534-5490
Mailing address:
  • Phone: 330-534-5408
  • Fax: 330-534-5490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30015561
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: