Provider Demographics
NPI:1437710241
Name:RUDSENSKE, BENJAMIN REESE (DMD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:REESE
Last Name:RUDSENSKE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1547
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130-1547
Mailing Address - Country:US
Mailing Address - Phone:601-853-3565
Mailing Address - Fax:601-853-3598
Practice Address - Street 1:7731 OLD CANTON RD STE A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6115
Practice Address - Country:US
Practice Address - Phone:601-853-3565
Practice Address - Fax:601-853-3598
Is Sole Proprietor?:No
Enumeration Date:2019-06-23
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4077-191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice