Provider Demographics
NPI:1497746440
Name:KRUSA, CHARLES JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOSEPH
Last Name:KRUSA
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 1:289 HIGHLAND SQ
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-5105
Mailing Address - Country:US
Mailing Address - Phone:931-484-3664
Mailing Address - Fax:931-707-5640
Practice Address - Street 1:289 HIGHLAND SQ
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-5105
Practice Address - Country:US
Practice Address - Phone:931-484-3664
Practice Address - Fax:931-707-5640
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS23931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice