Provider Demographics
NPI:1225548746
Name:ARCHBOLD FAMILY DENTAL-BRIAN A CUSTER DMD LLC
Entity Type:Organization
Organization Name:ARCHBOLD FAMILY DENTAL-BRIAN A CUSTER DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:CUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:419-445-8176
Mailing Address - Street 1:311 W HOLLAND ST
Mailing Address - Street 2:
Mailing Address - City:ARCHBOLD
Mailing Address - State:OH
Mailing Address - Zip Code:43502-1125
Mailing Address - Country:US
Mailing Address - Phone:419-445-8176
Mailing Address - Fax:419-445-8177
Practice Address - Street 1:311 W HOLLAND ST
Practice Address - Street 2:
Practice Address - City:ARCHBOLD
Practice Address - State:OH
Practice Address - Zip Code:43502-1125
Practice Address - Country:US
Practice Address - Phone:419-445-8176
Practice Address - Fax:419-445-8177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty