Provider Demographics
NPI:1336307784
Name:KENT A. CASERTA, DDS., INC.
Entity Type:Organization
Organization Name:KENT A. CASERTA, DDS., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:ANGELO
Authorized Official - Last Name:CASERTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:440-953-1733
Mailing Address - Street 1:38530 LAKE SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-7163
Mailing Address - Country:US
Mailing Address - Phone:440-953-1733
Mailing Address - Fax:440-946-1650
Practice Address - Street 1:38530 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-7163
Practice Address - Country:US
Practice Address - Phone:440-953-1733
Practice Address - Fax:440-946-1650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-01
Last Update Date:2008-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30015271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty