Provider Demographics
NPI:1124111323
Name:RUDD, MITCHELL G (DDS)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:G
Last Name:RUDD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 S 1300 E STE 6
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-3684
Mailing Address - Country:US
Mailing Address - Phone:801-487-0758
Mailing Address - Fax:801-487-0750
Practice Address - Street 1:1955 S 1300 E STE 6
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-3684
Practice Address - Country:US
Practice Address - Phone:801-487-0758
Practice Address - Fax:801-487-0750
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5328713-99221223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT01595375OtherUNITED CONCORDIA NUMBER