Provider Demographics
NPI:1639387814
Name:JUSINO, CARMEN TERESA (DMD)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:TERESA
Last Name:JUSINO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12233 REGAL LILY LANE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FLORIDA
Mailing Address - Zip Code:32827
Mailing Address - Country:UM
Mailing Address - Phone:954-643-0531
Mailing Address - Fax:
Practice Address - Street 1:12233 REGAL LILY LANE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FLORIDA
Practice Address - Zip Code:32827
Practice Address - Country:UM
Practice Address - Phone:954-643-0531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-19
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2784122300000X
FL19921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist