Basic Information
Provider Information | |||||||||
NPI: | 1942458450 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUDISILL | ||||||||
FirstName: | ASHLEY | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.D.S. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CRETELLA | ||||||||
OtherFirstName: | ASHLEY | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | D.D.S. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1 MEMORIAL MEDICAL DR | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296054407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8643512400 | ||||||||
FaxNumber: | 8643512420 | ||||||||
Practice Location | |||||||||
Address1: | 1 MEMORIAL MEDICAL DR | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296054407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8643512400 | ||||||||
FaxNumber: | 8643512420 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2008 | ||||||||
LastUpdateDate: | 02/14/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 4477 | SC | Y |   | Dental Providers | Dentist | General Practice |
No ID Information.