Provider Demographics
NPI:1205241510
Name:RUSTOM, JOSEPH (DDS)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:RUSTOM
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:PO BOX 1288
Mailing Address - Street 2:
Mailing Address - City:WINNFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71483-1288
Mailing Address - Country:US
Mailing Address - Phone:318-648-0375
Mailing Address - Fax:
Practice Address - Street 1:425 W LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:WINNFIELD
Practice Address - State:LA
Practice Address - Zip Code:71483-3463
Practice Address - Country:US
Practice Address - Phone:318-302-3261
Practice Address - Fax:318-302-3266
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6500122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist