Dennis J. Custer, D.D.S.
Individual provider Active NPI Dentist · Chippewa Lake, OH
NPI 1487727244 · NPPES record last updated Jul 8, 2007
Key facts
- NPI
- 1487727244
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 00117781 (OH)
- Practice address
- 511 Lee Lore Dr
Chippewa Lake, OH 44215-9722 - Phone
- (330) 769-3554
- Fax
- (330) 769-2026
- NPI assigned
- Nov 17, 2006
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 00117781 | OH | MD | Dentist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 00117781 | OH | Yes |
Addresses
Primary practice location
511 Lee Lore Dr
Chippewa Lake, OH 44215-9722
Mailing address
511 Lee Lore Dr
Chippewa Lake, OH 44215-9722
Phone (330) 769-3554
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0572518 | Medicaid | OH |
Other providers in Chippewa Lake, OH
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.