Provider Demographics
NPI:1376613539
Name:MASSIE, DANIEL LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:LEE
Last Name:MASSIE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N GIANT CITY RD
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-6410
Mailing Address - Country:US
Mailing Address - Phone:618-529-2711
Mailing Address - Fax:618-351-0393
Practice Address - Street 1:200 N GIANT CITY RD
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62902-6410
Practice Address - Country:US
Practice Address - Phone:618-529-2711
Practice Address - Fax:618-351-0393
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-0255101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL37-1408733OtherT.I.N.