=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255452942
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRENT A. RUSNAK, D.D.S, P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2007
-----------------------------------------------------
Last Update Date | 08/24/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7820 SHRADER RD
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23294-4222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-262-1060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7820 SHRADER RD
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23294-4222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-262-1060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DENTIST
-----------------------------------------------------
Name | DR. BRENT A RUSNAK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-262-1060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0401410886
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------