Provider Demographics
NPI:1710196365
Name:RUDACILLE, GARY L (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:RUDACILLE
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 1:3600 SCHEEL DR
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-1232
Mailing Address - Country:US
Mailing Address - Phone:410-531-5747
Mailing Address - Fax:
Practice Address - Street 1:9051 BALTIMORE NATIONAL PIKE
Practice Address - Street 2:SUITE 4D
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-3927
Practice Address - Country:US
Practice Address - Phone:410-465-5917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD57241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice