Healthcare Provider Details

I. General information

NPI: 1912640699
Provider Name (Legal Business Name): SARAH RUSTOM DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2521 AMES BLVD STE C
MARRERO LA
70072-5154
US

IV. Provider business mailing address

2521 AMES BLVD STE C
MARRERO LA
70072-5154
US

V. Phone/Fax

Practice location:
  • Phone: 504-340-9696
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7606
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number39724
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: