Provider Demographics
NPI:1528048493
Name:CUSACK, NATASHA IRENE (DDS)
Entity type:Individual
Prefix:DR
First Name:NATASHA
Middle Name:IRENE
Last Name:CUSACK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 E FENWICK RD
Mailing Address - Street 2:PO BOX 72
Mailing Address - City:FENWICK
Mailing Address - State:MI
Mailing Address - Zip Code:48834-9704
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2264 S STATE RD
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-2149
Practice Address - Country:US
Practice Address - Phone:616-527-6777
Practice Address - Fax:616-527-4647
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010183861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice