Provider Demographics
NPI:1497166235
Name:CUSIMANO, CHRISTIAN (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:
Last Name:CUSIMANO
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-2856
Mailing Address - Country:US
Mailing Address - Phone:208-467-4362
Mailing Address - Fax:208-463-9080
Practice Address - Street 1:345 W IOWA AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-2856
Practice Address - Country:US
Practice Address - Phone:208-467-4362
Practice Address - Fax:208-463-9080
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3247-OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics