MEDICARE: DR. MITCHELL G RUDD DDS

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	1223E0200X	Endodontics	5328713-9922	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01595375	OTHER	UT	UNITED CONCORDIA NUMBER

General Provider Information

NPI Number	:	1124111323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MITCHELL G RUDD DDS

Provider Business Mailing Address
First Line	:	1955 S 1300 E STE 6
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-3684
Country	:	US
Telephone Number	:	801-487-0758
Fax Number	:	801-487-0750

Provider Business Practice Location Address
First Line	:	1955 S 1300 E STE 6
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-3684
Country	:	US
Telephone Number	:	801-487-0758
Fax Number	:	801-487-0750

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	09/19/2008

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