Provider Demographics
NPI:1194131557
Name:RUSH, CORY MACKENZIE (DMD)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:MACKENZIE
Last Name:RUSH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2553 E LINDA LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-1305
Mailing Address - Country:US
Mailing Address - Phone:602-300-1059
Mailing Address - Fax:
Practice Address - Street 1:4350 E RAY RD STE 112
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-4705
Practice Address - Country:US
Practice Address - Phone:480-893-7674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX302051223G0001X
AZ9934122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice