Provider Demographics
NPI:1336566595
Name:RUDNITSKAYA, IRYNA M
Entity type:Individual
Prefix:
First Name:IRYNA
Middle Name:M
Last Name:RUDNITSKAYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 PEWAUKEE RD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2424
Mailing Address - Country:US
Mailing Address - Phone:262-271-5177
Mailing Address - Fax:
Practice Address - Street 1:1615 PEWAUKEE RD
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-2424
Practice Address - Country:US
Practice Address - Phone:262-271-5177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11356-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist