=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154672897
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRISTINA L RUST DMD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2012
-----------------------------------------------------
Last Update Date | 09/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11786 SW BARNES RD SUITE 360
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97225-5925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-646-1811
-----------------------------------------------------
Fax | 503-924-1698
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11786 SW BARNES RD SUITE 360
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97225-5925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-646-1811
-----------------------------------------------------
Fax | 503-924-1698
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CRISTINA L RUST
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 503-646-1811
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D-9483
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------