Provider Demographics
NPI:1417042102
Name:KAPUSTKA, ERIC (DDS)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:KAPUSTKA
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 1:125 JOHNSTOWN DR
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65742-9366
Mailing Address - Country:US
Mailing Address - Phone:417-753-2963
Mailing Address - Fax:417-753-3543
Practice Address - Street 1:125 JOHNSTOWN DR
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65742-9366
Practice Address - Country:US
Practice Address - Phone:417-753-2963
Practice Address - Fax:417-753-3543
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO144261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice