Individual
DR. THADDUS RUSIECKI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.D.S. PLLC
Contact information
Practice address
2602 CRANBERRY SQUARE, MORGANTOWN, WV 26505
(304) 594-1515
(304) 594-0785
Mailing address
2602 CRANBERRY SQ, MORGANTOWN, WV 26508-9201
(304) 594-1515
(304) 594-0785
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
3260-108
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000916438
BLUE SHIELD PROVIDER NUMB
WV
01
—
WV00411
HELATH PLAN PROVIDER NUMB
WV
Enumeration date
07/11/2006
Last updated
09/06/2011
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