Provider Demographics
NPI:1023553245
Name:CASTANEDA FASSIOLI, CAROLYN ELIZABETH
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ELIZABETH
Last Name:CASTANEDA FASSIOLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22706 ASPAN ST STE 602
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1603
Mailing Address - Country:US
Mailing Address - Phone:949-716-7000
Mailing Address - Fax:949-716-0600
Practice Address - Street 1:22706 ASPAN ST STE 602
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1603
Practice Address - Country:US
Practice Address - Phone:949-716-7000
Practice Address - Fax:949-716-0600
Is Sole Proprietor?:No
Enumeration Date:2016-12-23
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1010941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice