Provider Demographics
NPI:1821802000
Name:JERALD S. PRUNER, DMD, PLLC
Entity type:Organization
Organization Name:JERALD S. PRUNER, DMD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERALD
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:PRUNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:206-215-2088
Mailing Address - Street 1:1221 MADISON ST STE 1116
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-3536
Mailing Address - Country:US
Mailing Address - Phone:206-215-2088
Mailing Address - Fax:
Practice Address - Street 1:1221 MADISON ST STE 1116
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3536
Practice Address - Country:US
Practice Address - Phone:206-215-2088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-06
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery