Provider Demographics
NPI:1053541888
Name:RUDOLPH, MELISSA L (DDS)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8085 W BELL RD
Mailing Address - Street 2:SUITE #103
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-3825
Mailing Address - Country:US
Mailing Address - Phone:623-878-5400
Mailing Address - Fax:
Practice Address - Street 1:8085 W BELL RD
Practice Address - Street 2:SUITE #103
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-3825
Practice Address - Country:US
Practice Address - Phone:623-878-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD83721223X0400X
TX261661223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics