MICHAEL ROBERT CUSACK Dentist License verification

Business Entity

NOT RENEWED

License Type

Dentist

Description

LICENSED DENTIST CONTROLLED SUBSTANCE

License Number

31*****49

License Status

NOT RENEWED

Business

First Name

MICHAEL

Middle

ROBERT

Last Name

CUSACK

Business Name

MICHAEL ROBERT CUSACK

Original Issue Date

09/04/2007

Effective Date

10/04/2018

Expiration Date

01/31/2022

City

CHAMPAIGN

State

Zip

61822

County

CHAMPAIGN

Specialty/Qualifier

PRACTITIONER

Controlled Substance Schedule

II III IV

Ever Disciplined

LastModifiedDate

05/09/2022