Provider Demographics
NPI:1093782344
Name:PRUSINSKI, LEO (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:
Last Name:PRUSINSKI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:LEO
Other - Middle Name:GABRIEL
Other - Last Name:PRUSINSKI
Other - Suffix:II
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:2005 KNIGHT LANE NAVY MEDICINE SUPPORT COMMAND
Mailing Address - Street 2:ATTN: MEDICAL STAFF SERVICES BLDG. H
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212-0140
Mailing Address - Country:US
Mailing Address - Phone:904-542-7200
Mailing Address - Fax:
Practice Address - Street 1:2005 KNIGHT LANE NAVY MEDICINE SUPPORT COMMAND
Practice Address - Street 2:ATTN: MEDICAL STAFF SERVICES BLDG. H
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212-0140
Practice Address - Country:US
Practice Address - Phone:904-542-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008653A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist