Provider Demographics
NPI:1336329135
Name:CASSELL, JON WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:WILLIAM
Last Name:CASSELL
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 1:591 CAMINO DE LA REINA
Mailing Address - Street 2:SUITE 412
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3102
Mailing Address - Country:US
Mailing Address - Phone:619-220-7475
Mailing Address - Fax:619-220-7484
Practice Address - Street 1:591 CAMINO DE LA REINA
Practice Address - Street 2:SUITE 412
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3102
Practice Address - Country:US
Practice Address - Phone:619-220-7475
Practice Address - Fax:619-220-7484
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADPO339131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33913OtherDENTAL BOARD