Provider Demographics
NPI:1821054487
Name:LUSSMAN, MYRA M (DDS)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:M
Last Name:LUSSMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4090 WESTOWN PKWY
Mailing Address - Street 2:SUIT B
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-6760
Mailing Address - Country:US
Mailing Address - Phone:515-267-0737
Mailing Address - Fax:515-267-1480
Practice Address - Street 1:4090 WESTOWN PKWY
Practice Address - Street 2:SUIT B
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-6760
Practice Address - Country:US
Practice Address - Phone:515-267-0737
Practice Address - Fax:515-267-1480
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA79201223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1259457Medicare ID - Type Unspecified