Provider Demographics
NPI:1033207329
Name:RUSNAK, MARYKATE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARYKATE
Middle Name:
Last Name:RUSNAK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 MITCHELL DRIVE, SUITE 40
Mailing Address - Street 2:MOUNTAIN KIDS PEDIATRIC DENTISTRY
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525
Mailing Address - Country:US
Mailing Address - Phone:970-224-3600
Mailing Address - Fax:970-568-8577
Practice Address - Street 1:3600 MITCHELL DRIVE, SUITE 40
Practice Address - Street 2:MOUNTAIN KIDS PEDIATRIC DENTISTRY
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525
Practice Address - Country:US
Practice Address - Phone:970-224-3600
Practice Address - Fax:970-568-8577
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010669A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200826610Medicaid