Provider Demographics
NPI:1215202502
Name:CONRAD J KUSEL DDS PA
Entity Type:Organization
Organization Name:CONRAD J KUSEL DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CONRAD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KUSEL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:772-878-7525
Mailing Address - Street 1:491 SW PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2044
Mailing Address - Country:US
Mailing Address - Phone:772-878-7525
Mailing Address - Fax:772-340-1807
Practice Address - Street 1:491 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2044
Practice Address - Country:US
Practice Address - Phone:772-878-7525
Practice Address - Fax:772-340-1807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN-00111061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1912113606OtherGENERAL DENTISTRY
FL1043426778OtherGENRAL DENTISTRY