Provider Demographics
NPI:1578552592
Name:KUSHNER, MICHAEL BRUCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRUCE
Last Name:KUSHNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 DEMAREST DR
Mailing Address - Street 2:
Mailing Address - City:MENDHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07945-1524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1340 FOREST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-2002
Practice Address - Country:US
Practice Address - Phone:718-442-4440
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0343491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00772358Medicaid