Provider Demographics
NPI:1336887090
Name:419 DENTAL OF TOLEDO-CUSTER DMD, LLC.
Entity Type:Organization
Organization Name:419 DENTAL OF TOLEDO-CUSTER DMD, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:CUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:419-948-3384
Mailing Address - Street 1:5429 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-1930
Mailing Address - Country:US
Mailing Address - Phone:419-948-3384
Mailing Address - Fax:419-474-3456
Practice Address - Street 1:5429 SECOR RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-1930
Practice Address - Country:US
Practice Address - Phone:419-948-3384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental