Provider Demographics
NPI:1568590958
Name:PRUITT, RHONDA RENEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:RHONDA
Middle Name:RENEE
Last Name:PRUITT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7412 HIGHWAY 80
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-1430
Mailing Address - Country:US
Mailing Address - Phone:318-247-1111
Mailing Address - Fax:318-247-1222
Practice Address - Street 1:7412 HIGHWAY 80
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-1430
Practice Address - Country:US
Practice Address - Phone:318-247-1111
Practice Address - Fax:318-247-1222
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA52711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1852716Medicaid