1366455065 NPI number — CASSANDRA J SPITZLEY DDS

Table of content: CASSANDRA J SPITZLEY DDS (NPI 1366455065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366455065 NPI number — CASSANDRA J SPITZLEY DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPITZLEY
Provider First Name:
CASSANDRA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366455065
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14213 GOLF COURSE DR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BAXTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-829-4511
Provider Business Mailing Address Fax Number:
218-829-5483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14213 GOLF COURSE DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BAXTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-829-4511
Provider Business Practice Location Address Fax Number:
218-829-5483
Provider Enumeration Date:
08/14/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D10977 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)