Basic Information
| Provider Information | |||||||||
| NPI: | 1255960613 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSANOV | ||||||||
| FirstName: | RUSLAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 350 PINE ST | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577011669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057218939 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 350 PINE ST | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577011669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057218939 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2020 | ||||||||
| LastUpdateDate: | 05/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D1268 | SD | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 122300000X | 05 | SD | MEDICAID |