Provider Demographics
NPI:1700381308
Name:MURSIC, ZACHARY ALLEN
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:ALLEN
Last Name:MURSIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2548 S YOUNG CT
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-4197
Mailing Address - Country:US
Mailing Address - Phone:909-522-6462
Mailing Address - Fax:
Practice Address - Street 1:27382 CALLE ARROYO
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-2746
Practice Address - Country:US
Practice Address - Phone:949-701-5014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1021611223P0700X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0700XDental ProvidersDentistProsthodontics