Healthcare Provider Details

I. General information

NPI: 1265414536
Provider Name (Legal Business Name): JEROME S KUSTIN D.D.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5455 BROADVIEW RD. #100
PARMA OH
44134
US

IV. Provider business mailing address

5455 BROADVIEW RD. #100
PARMA OH
44134
US

V. Phone/Fax

Practice location:
  • Phone: 216-741-4600
  • Fax: 216-749-0960
Mailing address:
  • Phone: 216-741-4600
  • Fax: 216-749-0960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12902
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12902
License Number StateOH

VIII. Authorized Official

Name: DR. JEROME S KUSTIN
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 216-741-4600