MEDICARE: STEPHEN A. RENDULICH, DDS, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	7749	NC

General Provider Information

NPI Number	:	1013173483
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STEPHEN A. RENDULICH, DDS, PA

Provider Business Mailing Address
First Line	:	10210 HICKORYWOOD HILL AVE
Second Line	:	SUITE 200
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-3332
Country	:	US
Telephone Number	:	704-875-8833
Fax Number	:	704-875-0303

Provider Business Practice Location Address
First Line	:	10210 HICKORYWOOD HILL AVE
Second Line	:	SUITE 200
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-3332
Country	:	US
Telephone Number	:	704-875-8833
Fax Number	:	704-875-0303

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	LORA SIGMON
Credential	:
Telephone Number	:	704-875-8833

Provider Enumeration Date	:	08/05/2008
Last Update Date	:	08/05/2008

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