Provider Demographics
NPI:1609905645
Name:PRUST, REBECCA HAVEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:HAVEL
Last Name:PRUST
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:REBECCA
Other - Middle Name:ANN
Other - Last Name:HAVEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:1223 LAKE STREET
Mailing Address - Street 2:
Mailing Address - City:ALGOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54201
Mailing Address - Country:US
Mailing Address - Phone:920-469-1167
Mailing Address - Fax:
Practice Address - Street 1:1223 LAKE STREET
Practice Address - Street 2:
Practice Address - City:ALGOMA
Practice Address - State:WI
Practice Address - Zip Code:54201
Practice Address - Country:US
Practice Address - Phone:920-487-5648
Practice Address - Fax:920-487-5658
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5658-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice