Healthcare Provider Details

I. General information

NPI: 1255628491
Provider Name (Legal Business Name): RONALD J PRUHS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 S LAKE DR APT. 251
SAINT FRANCIS WI
53235-5954
US

IV. Provider business mailing address

4120 S LAKE DR APT. 251
SAINT FRANCIS WI
53235-5954
US

V. Phone/Fax

Practice location:
  • Phone: 920-693-2992
  • Fax:
Mailing address:
  • Phone: 920-693-2992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5000087-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: