Provider Demographics
NPI:1184004996
Name:VAN TASSELL, DUSTIN E (DDS)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:E
Last Name:VAN TASSELL
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 1:2200 KELL BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76309-4401
Mailing Address - Country:US
Mailing Address - Phone:940-322-2252
Mailing Address - Fax:940-322-7090
Practice Address - Street 1:2200 KELL BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76309-4401
Practice Address - Country:US
Practice Address - Phone:940-322-2252
Practice Address - Fax:940-322-7090
Is Sole Proprietor?:No
Enumeration Date:2015-06-06
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX317261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice