Provider Demographics
NPI:1891083515
Name:RUSNAK, JONATHON EDWARD (DDS)
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:EDWARD
Last Name:RUSNAK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5911
Mailing Address - Country:US
Mailing Address - Phone:337-474-3636
Mailing Address - Fax:337-474-0110
Practice Address - Street 1:2629 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5911
Practice Address - Country:US
Practice Address - Phone:337-474-3636
Practice Address - Fax:337-474-0110
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-15
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6067122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist