Provider Demographics
NPI:1407844327
Name:RUST, AUSTIN R (DMD MPA)
Entity Type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:R
Last Name:RUST
Suffix:
Gender:M
Credentials:DMD MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E MONTCLAIR ST
Mailing Address - Street 2:APT. 3A
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7911
Mailing Address - Country:US
Mailing Address - Phone:417-343-9651
Mailing Address - Fax:
Practice Address - Street 1:202 E MONTCLAIR ST
Practice Address - Street 2:APT. 3A
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7911
Practice Address - Country:US
Practice Address - Phone:417-343-9651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0122621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO400035531Medicaid