Provider Demographics
NPI:1427053040
Name:RAKUSIN, HEDLEY
Entity type:Individual
Prefix:DR
First Name:HEDLEY
Middle Name:
Last Name:RAKUSIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11910 GREENVILLE AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3564
Mailing Address - Country:US
Mailing Address - Phone:972-644-1162
Mailing Address - Fax:972-783-6660
Practice Address - Street 1:11910 GREENVILLE AVE
Practice Address - Street 2:STE 110
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-3564
Practice Address - Country:US
Practice Address - Phone:972-644-1162
Practice Address - Fax:972-783-6660
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX148861223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics