Provider Demographics
NPI:1497806954
Name:JUSINO, THOMAS DAHL (DDS, MS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:DAHL
Last Name:JUSINO
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 1:30330 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3821
Mailing Address - Country:US
Mailing Address - Phone:248-851-5710
Mailing Address - Fax:248-851-7823
Practice Address - Street 1:30330 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3821
Practice Address - Country:US
Practice Address - Phone:248-851-5710
Practice Address - Fax:248-851-7823
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010128101223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics