Provider Demographics
NPI:1275718710
Name:BRUCE L. CASSIS
Entity Type:Organization
Organization Name:BRUCE L. CASSIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CASSIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-574-0424
Mailing Address - Street 1:138 LIVELY ST
Mailing Address - Street 2:P. O. BOX 926
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-1148
Mailing Address - Country:US
Mailing Address - Phone:304-574-0424
Mailing Address - Fax:304-574-2102
Practice Address - Street 1:138 LIVELY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-1148
Practice Address - Country:US
Practice Address - Phone:304-574-0424
Practice Address - Fax:304-574-2102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810007224Medicaid