Healthcare Provider Details

I. General information

NPI: 1518118454
Provider Name (Legal Business Name): MICHAEL J. CUSATIS DDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2008
Last Update Date: 11/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 S OTSEGO AVE STE B
GAYLORD MI
49735-9524
US

IV. Provider business mailing address

1507 S OTSEGO AVE STE B
GAYLORD MI
49735-9524
US

V. Phone/Fax

Practice location:
  • Phone: 989-732-4189
  • Fax: 989-732-1916
Mailing address:
  • Phone: 989-732-4189
  • Fax: 989-732-1916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD14500
License Number StateMI

VIII. Authorized Official

Name: DR. MICHAEL J. CUSATIS
Title or Position: OWNER
Credential: DDS
Phone: 989-732-4189