Healthcare Provider Details

I. General information

NPI: 1487727244
Provider Name (Legal Business Name): DENNIS J. CUSTER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 LEE LORE DR
CHIPPEWA LAKE OH
44215-9722
US

IV. Provider business mailing address

511 LEE LORE DR
CHIPPEWA LAKE OH
44215-9722
US

V. Phone/Fax

Practice location:
  • Phone: 330-769-3554
  • Fax: 330-769-2026
Mailing address:
  • Phone: 330-769-3554
  • Fax: 330-769-2026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number00117781
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: