Provider Demographics
NPI:1134234313
Name:PRUNER, JERALD S (DMD)
Entity type:Individual
Prefix:
First Name:JERALD
Middle Name:S
Last Name:PRUNER
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 1:1221 MADISON ST STE 1116
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-3536
Mailing Address - Country:US
Mailing Address - Phone:206-215-2088
Mailing Address - Fax:
Practice Address - Street 1:1221 MADISON ST STE 1116
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3536
Practice Address - Country:US
Practice Address - Phone:206-215-2088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000105271223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery