Provider Demographics
NPI:1174837751
Name:PRUSA, STEPHANIE LYNN (DENTAL HYGIENIST)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:LYNN
Last Name:PRUSA
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10814 W 101ST TER
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66214-2532
Mailing Address - Country:US
Mailing Address - Phone:913-526-8549
Mailing Address - Fax:
Practice Address - Street 1:753 STATE AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66101-2516
Practice Address - Country:US
Practice Address - Phone:913-321-4385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11287124Q00000X
MO2010022535124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1841288974Medicaid
KS1407988710Medicaid