Provider Demographics
NPI:1699811380
Name:KITUSKIE, LEO J (DMD)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:J
Last Name:KITUSKIE
Suffix:
Gender:M
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:PO BOX 341
Mailing Address - Street 2:
Mailing Address - City:GWYNEDD VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19437-0341
Mailing Address - Country:US
Mailing Address - Phone:609-641-1065
Mailing Address - Fax:609-645-0162
Practice Address - Street 1:50 W BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08232-2645
Practice Address - Country:US
Practice Address - Phone:609-641-1065
Practice Address - Fax:609-645-0162
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI017633001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics