Provider Demographics
NPI:1407989221
Name:SASSACK, WALTER R (DDS PC)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:R
Last Name:SASSACK
Suffix:
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17711 FORT ST
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-6632
Mailing Address - Country:US
Mailing Address - Phone:734-283-2818
Mailing Address - Fax:734-283-2888
Practice Address - Street 1:17711 FORT ST
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-6632
Practice Address - Country:US
Practice Address - Phone:734-283-2818
Practice Address - Fax:734-283-2888
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI126611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice