Provider Demographics
NPI:1174675185
Name:RUSANOWSKI, KENNETH BRIAN (DDS)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:BRIAN
Last Name:RUSANOWSKI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CALLE MEDICO
Mailing Address - Street 2:STE 2
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:505-988-2611
Mailing Address - Fax:505-820-0397
Practice Address - Street 1:2 CALLE MEDICO
Practice Address - Street 2:STE 2
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-988-2611
Practice Address - Fax:505-820-0397
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD15851223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics