Provider Demographics
NPI:1720031115
Name:SASSACK, RUSSELL A (DDS)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:A
Last Name:SASSACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43771 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-2445
Mailing Address - Country:US
Mailing Address - Phone:586-323-2273
Mailing Address - Fax:586-323-9460
Practice Address - Street 1:43771 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-2445
Practice Address - Country:US
Practice Address - Phone:586-323-2273
Practice Address - Fax:586-323-9460
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI138171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI202034814OtherEIN