Provider Demographics
NPI:1962662304
Name:RUDZIEWICZ, DAVID T (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:T
Last Name:RUDZIEWICZ
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 1:2020 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3741
Mailing Address - Country:US
Mailing Address - Phone:773-549-0417
Mailing Address - Fax:
Practice Address - Street 1:2020 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3741
Practice Address - Country:US
Practice Address - Phone:773-549-0417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019021382122300000X
WI10024911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist