Provider Demographics
NPI:1558774885
Name:PRUSIK, DUSTIN JACOB (DDS)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:JACOB
Last Name:PRUSIK
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 1:230 DOVE COTTAGE LN
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519-0505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:230 DOVE COTTAGE LN
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27519-0505
Practice Address - Country:US
Practice Address - Phone:919-345-1501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice