Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 30.023574 | OH |
NPI | 1093031742 |
---|---|
Provider Name | Lisa Marie Rudolph |
First Address | Cincinnati, OH 45229-3026 |
Second Address | Cincinnati, OH 45229-3026 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/04/2010 |
Last Update Date | 30/07/2013 |