Provider Demographics
NPI:1437184496
Name:RUSIECKI, THADDUS (DDS PLLC)
Entity Type:Individual
Prefix:DR
First Name:THADDUS
Middle Name:
Last Name:RUSIECKI
Suffix:
Gender:M
Credentials:DDS PLLC
Other - Prefix:DR
Other - First Name:THAD
Other - Middle Name:
Other - Last Name:RUSIECKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS PLLC
Mailing Address - Street 1:2602 CRANBERRY SQ
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-9201
Mailing Address - Country:US
Mailing Address - Phone:304-594-1515
Mailing Address - Fax:304-594-0785
Practice Address - Street 1:2602 CRANBERRY SQUARE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505
Practice Address - Country:US
Practice Address - Phone:304-594-1515
Practice Address - Fax:304-594-0785
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3260-1081223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV00411OtherHELATH PLAN PROVIDER NUMB
WV000916438OtherBLUE SHIELD PROVIDER NUMB
WVU88904Medicare UPIN