Provider Demographics
NPI:1457543423
Name:CASSILL, ELLEN BARBARA (RDH)
Entity type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:BARBARA
Last Name:CASSILL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18526 DRIFTWOOD DR E
Mailing Address - Street 2:
Mailing Address - City:LAKE TAPPS
Mailing Address - State:WA
Mailing Address - Zip Code:98391
Mailing Address - Country:US
Mailing Address - Phone:253-862-7819
Mailing Address - Fax:
Practice Address - Street 1:18526 DRIFTWOOD DR E
Practice Address - Street 2:
Practice Address - City:LAKE TAPPS
Practice Address - State:WA
Practice Address - Zip Code:98391-9466
Practice Address - Country:US
Practice Address - Phone:253-862-7819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00002017124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5902058Medicaid