Provider Demographics
NPI:1124171988
Name:RUST, MARY ANTOINETTE (DDS)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANTOINETTE
Last Name:RUST
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5542 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-2726
Mailing Address - Country:US
Mailing Address - Phone:215-482-4250
Mailing Address - Fax:
Practice Address - Street 1:5542 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-2726
Practice Address - Country:US
Practice Address - Phone:215-482-4250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS023869L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice