1609905645 NPI number — DR. REBECCA HAVEL PRUST D.D.S.

Table of content: DR. REBECCA HAVEL PRUST D.D.S. (NPI 1609905645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609905645 NPI number — DR. REBECCA HAVEL PRUST D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUST
Provider First Name:
REBECCA
Provider Middle Name:
HAVEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HAVEL
Provider Other First Name:
REBECCA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.D.S.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1609905645
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1223 LAKE STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALGOMA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-469-1167
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1223 LAKE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALGOMA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-487-5648
Provider Business Practice Location Address Fax Number:
920-487-5658
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5658-015 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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