Provider Demographics
NPI:1417079906
Name:SHUSTAK DENTAL GROUP, INC.
Entity Type:Organization
Organization Name:SHUSTAK DENTAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:SHUSTAK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-754-7799
Mailing Address - Street 1:255 PARK AVE
Mailing Address - Street 2:SUITE 509
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-1953
Mailing Address - Country:US
Mailing Address - Phone:508-754-7799
Mailing Address - Fax:508-754-8558
Practice Address - Street 1:255 PARK AVE
Practice Address - Street 2:SUITE 509
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-1953
Practice Address - Country:US
Practice Address - Phone:508-754-7799
Practice Address - Fax:508-754-8558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA14677122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty