Provider Demographics
NPI:1265061329
Name:RUSNAK, KATHLEEN MARIE
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:RUSNAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13991 ROUTE 78
Mailing Address - Street 2:
Mailing Address - City:SOUTH WALES
Mailing Address - State:NY
Mailing Address - Zip Code:14139-9519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3364 SOUTHWESTERN BLVD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1524
Practice Address - Country:US
Practice Address - Phone:716-332-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0624611223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry