Healthcare Provider Details

I. General information

NPI: 1699811380
Provider Name (Legal Business Name): LEO J. KITUSKIE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 W BLACK HORSE PIKE
PLEASANTVILLE NJ
08232-2645
US

IV. Provider business mailing address

PO BOX 341
GWYNEDD VALLEY PA
19437-0341
US

V. Phone/Fax

Practice location:
  • Phone: 609-641-1065
  • Fax: 609-645-0162
Mailing address:
  • Phone: 609-641-1065
  • Fax: 609-645-0162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number22DI01763300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: