Healthcare Provider Details

I. General information

NPI: 1174675185
Provider Name (Legal Business Name): KENNETH BRIAN RUSANOWSKI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CALLE MEDICO STE 2
SANTA FE NM
87505
US

IV. Provider business mailing address

2 CALLE MEDICO STE 2
SANTA FE NM
87505
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-2611
  • Fax: 505-820-0397
Mailing address:
  • Phone: 505-988-2611
  • Fax: 505-820-0397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDD1585
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: