Provider Demographics
NPI:1487727244
Name:CUSTER, DENNIS J (DDS)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:J
Last Name:CUSTER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 LEE LORE DR
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44215-9722
Mailing Address - Country:US
Mailing Address - Phone:330-769-3554
Mailing Address - Fax:330-769-2026
Practice Address - Street 1:511 LEE LORE DR
Practice Address - Street 2:
Practice Address - City:CHIPPEWA LAKE
Practice Address - State:OH
Practice Address - Zip Code:44215-9722
Practice Address - Country:US
Practice Address - Phone:330-769-3554
Practice Address - Fax:330-769-2026
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00117781122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0572518Medicaid