Provider Demographics
NPI:1780736298
Name:COUSINS, MICHAEL C (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:C
Last Name:COUSINS
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 1:1312 OAKLAND DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-1205
Mailing Address - Country:US
Mailing Address - Phone:269-337-3000
Mailing Address - Fax:
Practice Address - Street 1:1312 OAKLAND DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1205
Practice Address - Country:US
Practice Address - Phone:269-337-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010155311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice