MEDICARE: BRADY DEE RUSK DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12703	TX

General Provider Information

NPI Number	:	1770664567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADY DEE RUSK DDS

Provider Business Mailing Address
First Line	:	104 S OLD BETSY RD
Second Line	:
City	:	KEENE
State	:	TX
Zip	:	76059
Country	:	US
Telephone Number	:	817-641-2272
Fax Number	:	817-641-2272

Provider Business Practice Location Address
First Line	:	104 S OLD BETSY RD
Second Line	:
City	:	KEENE
State	:	TX
Zip	:	76059
Country	:	US
Telephone Number	:	817-641-2272
Fax Number	:	817-641-2272

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2006
Last Update Date	:	07/08/2007

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