Active NPI
Mark G Prusacki, DDS
- General Practice Dentistry
- Phoenix, AZ
National Provider Identifier
1467667071
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 4705
- Practice address
- 16415 S 46TH Way
Phoenix, AZ 85048-0158 - Phone
- (480) 567-4212
- NPI assigned
- May 14, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 4705 | AZ | Primary |
Addresses
Primary practice location
16415 S 46TH Way
Phoenix, AZ 85048-0158
Mailing address
16415 S 46TH Way
Phoenix, AZ 85048-0158
Phone (480) 753-0529
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in TX
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160607000735 | TX | Order and Referring Only - Other (Physician) | 3375833130 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4705 | AZ | MD | Veterinarian |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1179100800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1372291200000",
"number": "1467667071",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "16415 S 46TH WAY",
"city": "PHOENIX",
"state": "AZ",
"postal_code": "850480158",
"telephone_number": "480-753-0529"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "16415 S 46TH WAY",
"city": "PHOENIX",
"state": "AZ",
"postal_code": "850480158",
"telephone_number": "480-567-4212"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PRUSACKI",
"first_name": "MARK",
"middle_name": "G",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-05-14",
"last_updated": "2013-06-27",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "AZ",
"license": "4705",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Phoenix, AZ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 27, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.