Provider Demographics
NPI:1265414536
Name:JEROME S KUSTIN D.D.S.
Entity type:Organization
Organization Name:JEROME S KUSTIN D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:S
Authorized Official - Last Name:KUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:216-741-4600
Mailing Address - Street 1:5455 BROADVIEW RD.
Mailing Address - Street 2:#100
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134
Mailing Address - Country:US
Mailing Address - Phone:216-741-4600
Mailing Address - Fax:216-749-0960
Practice Address - Street 1:5455 BROADVIEW RD.
Practice Address - Street 2:#100
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134
Practice Address - Country:US
Practice Address - Phone:216-741-4600
Practice Address - Fax:216-749-0960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH129021223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty