=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376730200
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL ROBERT CUSACK D.M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2007
-----------------------------------------------------
Last Update Date | 04/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2323 W 2ND AVE STE B
-----------------------------------------------------
City | DURANGO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81301-4646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-274-0074
-----------------------------------------------------
Fax | 309-699-7050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2323 W 2ND AVE STE B
-----------------------------------------------------
City | DURANGO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81301-4646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-327-6155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DEN.00204574
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DD3375
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019-027507
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------