Provider Demographics
NPI:1700805652
Name:CUSATIS, MICHAEL JOSEPH (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:CUSATIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 S. OTSEGO
Mailing Address - Street 2:SUITE B
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735
Mailing Address - Country:US
Mailing Address - Phone:989-732-4189
Mailing Address - Fax:989-732-1916
Practice Address - Street 1:1507 S. OTSEGO
Practice Address - Street 2:SUITE B
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735
Practice Address - Country:US
Practice Address - Phone:989-732-4189
Practice Address - Fax:989-732-1916
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID145001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI56910090OtherBCBS ID #
MI5190276Medicaid
MI56910090OtherBCBS ID #