Provider Demographics
NPI:1861454282
Name:CUSTELCEAN, CORINA ADELAIDA
Entity Type:Individual
Prefix:
First Name:CORINA
Middle Name:ADELAIDA
Last Name:CUSTELCEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8376 OLD TROY PIKE
Mailing Address - Street 2:
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424-1028
Mailing Address - Country:US
Mailing Address - Phone:937-938-7678
Mailing Address - Fax:
Practice Address - Street 1:8376 OLD TROY PIKE
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-1028
Practice Address - Country:US
Practice Address - Phone:937-938-7678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0220871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2603392Medicaid
OH9181221OtherDORAL