Provider Demographics
NPI:1962405845
Name:RADECKI, CASS ANTHONY (DDS)
Entity type:Individual
Prefix:DR
First Name:CASS
Middle Name:ANTHONY
Last Name:RADECKI
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 1:203 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-1329
Mailing Address - Country:US
Mailing Address - Phone:734-429-1384
Mailing Address - Fax:734-944-8038
Practice Address - Street 1:203 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-1329
Practice Address - Country:US
Practice Address - Phone:734-429-1384
Practice Address - Fax:734-944-8038
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010147711223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU21982Medicare UPIN