Provider Demographics
NPI:1619169521
Name:TERRANCE A. RUST, D.D.S., INC.
Entity Type:Organization
Organization Name:TERRANCE A. RUST, D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GERVASE
Authorized Official - Suffix:
Authorized Official - Credentials:RDA
Authorized Official - Phone:530-223-1811
Mailing Address - Street 1:2315 BECHELLI LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-0119
Mailing Address - Country:US
Mailing Address - Phone:530-223-1811
Mailing Address - Fax:530-223-1813
Practice Address - Street 1:2315 BECHELLI LN
Practice Address - Street 2:SUITE A
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-0119
Practice Address - Country:US
Practice Address - Phone:530-223-1811
Practice Address - Fax:530-223-1813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA195251223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB195250-01OtherMEDI-CAL
CAB195250-01OtherMEDI-CAL