Healthcare Provider Details

I. General information

NPI: 1275730798
Provider Name (Legal Business Name): JULIE ANNE PRUNESKI D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JULIE ANNE CORBIN D.D.S.

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 COOPER FOSTER PARK RD
LORAIN OH
44053
US

IV. Provider business mailing address

690 COOPER FOSTER PARK RD
LORAIN OH
44053
US

V. Phone/Fax

Practice location:
  • Phone: 440-282-2023
  • Fax: 440-233-5401
Mailing address:
  • Phone: 440-282-2023
  • Fax: 440-233-5401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.022674
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number2631
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: