Provider Demographics
NPI:1932537875
Name:RUST, RAYMOND JR
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:RUST
Suffix:JR
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 1:510 W 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-1564
Mailing Address - Country:US
Mailing Address - Phone:509-865-5600
Mailing Address - Fax:509-865-5783
Practice Address - Street 1:510 W 1ST AVE
Practice Address - Street 2:
Practice Address - City:TOPPENISH
Practice Address - State:WA
Practice Address - Zip Code:98948-1564
Practice Address - Country:US
Practice Address - Phone:509-865-5600
Practice Address - Fax:509-865-5783
Is Sole Proprietor?:No
Enumeration Date:2013-10-30
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62794122300000X
WADE60409006122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist