Healthcare Provider Details

I. General information

NPI: 1245407550
Provider Name (Legal Business Name): DR. CLARENCE E KUSIK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N50 W34838 WISCONSIN AVE.
OKAUCHEE WI
53069
US

IV. Provider business mailing address

N50 W34838 WISCONSIN AVE.
OKAUCHEE WI
53069
US

V. Phone/Fax

Practice location:
  • Phone: 262-567-3171
  • Fax:
Mailing address:
  • Phone: 262-567-3171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5000432015
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number5000432-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: