Provider Demographics
NPI:1821102872
Name:CUSHMAN, ROBERT DOUGLAS (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DOUGLAS
Last Name:CUSHMAN
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 1:1100 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-2112
Mailing Address - Country:US
Mailing Address - Phone:810-364-9900
Mailing Address - Fax:810-364-9901
Practice Address - Street 1:1100 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-2112
Practice Address - Country:US
Practice Address - Phone:810-364-9900
Practice Address - Fax:810-364-9901
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901009408122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4020351Medicaid