Healthcare Provider Details

I. General information

NPI: 1558511493
Provider Name (Legal Business Name): MIGUEL ANGEL JUSINO DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2008
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28901 TRAILS EDGE BLVD STE 103
BONITA SPRINGS FL
34134-7588
US

IV. Provider business mailing address

6841 LIVINGSTON WOODS LN
NAPLES FL
34109-3835
US

V. Phone/Fax

Practice location:
  • Phone: 239-913-6780
  • Fax: 239-301-2611
Mailing address:
  • Phone: 787-431-7479
  • Fax: 239-301-2611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2824
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN23154
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number125980
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: