Provider Demographics
NPI:1346060217
Name:WILLIAM E. CUSACK, D.D.S., LTD.
Entity type:Organization
Organization Name:WILLIAM E. CUSACK, D.D.S., LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:CUSACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-360-8592
Mailing Address - Street 1:5013 N UNIVERSITY ST STE 2
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4796
Mailing Address - Country:US
Mailing Address - Phone:309-693-2220
Mailing Address - Fax:309-693-2272
Practice Address - Street 1:5013 N UNIVERSITY ST STE 2
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4796
Practice Address - Country:US
Practice Address - Phone:309-693-2220
Practice Address - Fax:309-693-2272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty