Healthcare Provider Details

I. General information

NPI: 1033207329
Provider Name (Legal Business Name): MARYKATE RUSNAK D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 08/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 MITCHELL DRIVE, SUITE 40 MOUNTAIN KIDS PEDIATRIC DENTISTRY
FORT COLLINS CO
80525
US

IV. Provider business mailing address

3600 MITCHELL DRIVE, SUITE 40 MOUNTAIN KIDS PEDIATRIC DENTISTRY
FORT COLLINS CO
80525
US

V. Phone/Fax

Practice location:
  • Phone: 970-224-3600
  • Fax: 970-568-8577
Mailing address:
  • Phone: 970-224-3600
  • Fax: 970-568-8577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number12010669A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200826610
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: