MEDICARE: DR. RONALD LOUIS SUDOMIR 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	122300000X	Dentist	2901016798	MI

General Provider Information

NPI Number	:	1598835399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RONALD LOUIS SUDOMIR DDS

Provider Business Mailing Address
First Line	:	1147 E LONG LAKE RD
Second Line	:	SUITE 3
City	:	TROY
State	:	MI
Zip	:	48085-4943
Country	:	US
Telephone Number	:	248-524-1280
Fax Number	:	248-524-1254

Provider Business Practice Location Address
First Line	:	1147 E LONG LAKE RD
Second Line	:	SUITE 3
City	:	TROY
State	:	MI
Zip	:	48085-4943
Country	:	US
Telephone Number	:	248-524-1280
Fax Number	:	248-524-1254

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

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	07/08/2007

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