Provider Demographics
NPI:1699778159
Name:FUESTING, MIKE L (DMD)
Entity type:Individual
Prefix:DR
First Name:MIKE
Middle Name:L
Last Name:FUESTING
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 N GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-3849
Mailing Address - Country:US
Mailing Address - Phone:217-442-4267
Mailing Address - Fax:217-442-4284
Practice Address - Street 1:1004 N GILBERT ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3849
Practice Address - Country:US
Practice Address - Phone:217-442-4267
Practice Address - Fax:217-442-4284
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice