Healthcare Provider Details

I. General information

NPI: 1992921092
Provider Name (Legal Business Name): THAD RUSIECKI, DDS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2602 CRANBERRY SQUARE
MORGANTOWN WV
26505
US

IV. Provider business mailing address

2602 CRANBERRY SQUARE
MORGANTOWN WV
26505
US

V. Phone/Fax

Practice location:
  • Phone: 304-594-1515
  • Fax: 304-594-0785
Mailing address:
  • Phone: 304-594-1515
  • Fax: 304-594-0785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3260
License Number StateWV

VIII. Authorized Official

Name: THAD RUSIECKI
Title or Position: OWNER
Credential: DDS
Phone: 304-594-1515