Healthcare Provider Details

I. General information

NPI: 1154521201
Provider Name (Legal Business Name): RUPESH R UDESHI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 04/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 ATWOOD AVE SUITE #350
JOHNSTON RI
02919-4839
US

IV. Provider business mailing address

1414 ATWOOD AVE SUITE #350
JOHNSTON RI
02919-4839
US

V. Phone/Fax

Practice location:
  • Phone: 401-331-7665
  • Fax:
Mailing address:
  • Phone: 401-331-7665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number22217
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number053566
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN03011
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number009884
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: