Provider Demographics
NPI:1528078045
Name:ROBERT CASSELL DDS PC WASILLA DENTAL CENTER
Entity type:Organization
Organization Name:ROBERT CASSELL DDS PC WASILLA DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:CASSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-376-5315
Mailing Address - Street 1:351 W SWANSON
Mailing Address - Street 2:1
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-376-5315
Mailing Address - Fax:907-376-7855
Practice Address - Street 1:351 W SWANSON
Practice Address - Street 2:1
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-376-5315
Practice Address - Fax:907-376-7855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK706122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty