Provider Demographics
NPI:1508020330
Name:PRUSACK, LOUIS ROBERT (DDS)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:ROBERT
Last Name:PRUSACK
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 1:57 STREET RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3100
Mailing Address - Country:US
Mailing Address - Phone:215-355-3513
Mailing Address - Fax:215-355-3513
Practice Address - Street 1:57 STREET RD
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3100
Practice Address - Country:US
Practice Address - Phone:215-355-3513
Practice Address - Fax:215-355-3513
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS016805L1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry