=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992921092
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THAD RUSIECKI, DDS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2007
-----------------------------------------------------
Last Update Date | 09/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2602 CRANBERRY SQUARE
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-594-1515
-----------------------------------------------------
Fax | 304-594-0785
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2602 CRANBERRY SQUARE
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-594-1515
-----------------------------------------------------
Fax | 304-594-0785
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | THAD RUSIECKI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 304-594-1515
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 3260
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------