Provider Demographics
NPI:1477833119
Name:PRUSKY, SEAN DAVID (DDS)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:DAVID
Last Name:PRUSKY
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 1:500 S SEPULVEDA BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-6976
Mailing Address - Country:US
Mailing Address - Phone:310-754-5460
Mailing Address - Fax:
Practice Address - Street 1:500 S SEPULVEDA BLVD STE 301
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-6976
Practice Address - Country:US
Practice Address - Phone:310-754-5460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA606711223G0001X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice