Provider Demographics
NPI:1407835069
Name:CASILLAS, MICHAEL A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:CASILLAS
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 1:6501 BLANCO RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216
Mailing Address - Country:US
Mailing Address - Phone:210-341-7264
Mailing Address - Fax:210-341-2022
Practice Address - Street 1:6501 BLANCO RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216
Practice Address - Country:US
Practice Address - Phone:210-341-7264
Practice Address - Fax:210-341-2022
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX158971223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
731009960006OtherTRICARE
838355OtherUNITED CONCORDIA
80W703OtherBCBS
838355OtherUNITED CONCORDIA
80W703Medicare ID - Type Unspecified