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General NPI Number Information
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NPI Number | 1144396565
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Entity Type | Individual
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Provider Name | JOHN RENOUARD CUSHING JR. DDS
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Gender | Male
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Dates
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Enumeration Date | 11/28/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4216 PONTIAC LAKE ROAD GREAT EXPRESSIONS
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City | WATERFORD
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State | MI
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Zip | 48328
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Country | US
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Telephone | 248-674-1009
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Fax | 248-674-9615
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Provider Business Mailing Address
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Address Line | 1976 WARBLER CT
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City | TROY
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State | MI
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Zip | 48084
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Country | US
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Telephone | 248-649-1498
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 11243
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License Number State | MI
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