Provider Demographics
NPI:1164648911
Name:MARUSICH, WILLIAM MICHAEL (DDS,MS)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:MICHAEL
Last Name:MARUSICH
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2404
Mailing Address - Country:US
Mailing Address - Phone:607-797-1310
Mailing Address - Fax:607-797-0917
Practice Address - Street 1:190 MAIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2404
Practice Address - Country:US
Practice Address - Phone:607-797-1310
Practice Address - Fax:607-797-0917
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0378401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice