Provider Demographics
NPI:1467667071
Name:PRUSACKI, MARK G (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:PRUSACKI
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 1:16415 S 46TH WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0158
Mailing Address - Country:US
Mailing Address - Phone:480-753-0529
Mailing Address - Fax:
Practice Address - Street 1:16415 S 46TH WAY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-0158
Practice Address - Country:US
Practice Address - Phone:480-567-4212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ47051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice