Provider Demographics
NPI:1245407550
Name:KUSIK, CLARENCE E
Entity type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:E
Last Name:KUSIK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N50 W34838 WISCONSIN AVE.
Mailing Address - Street 2:
Mailing Address - City:OKAUCHEE
Mailing Address - State:WI
Mailing Address - Zip Code:53069
Mailing Address - Country:US
Mailing Address - Phone:262-567-3171
Mailing Address - Fax:
Practice Address - Street 1:N50 W34838 WISCONSIN AVE.
Practice Address - Street 2:
Practice Address - City:OKAUCHEE
Practice Address - State:WI
Practice Address - Zip Code:53069
Practice Address - Country:US
Practice Address - Phone:262-567-3171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5000432015122300000X
WI5000432-15261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33506100Medicaid
1831369008OtherMAYFAIR DENTAL S.C.
WI38380800Medicaid