Provider Demographics
NPI:1497000178
Name:GLEN T. CASTO DDS, MDS, PA
Entity Type:Organization
Organization Name:GLEN T. CASTO DDS, MDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-388-6400
Mailing Address - Street 1:621 SEBASTIAN BLVD
Mailing Address - Street 2:B
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-4309
Mailing Address - Country:US
Mailing Address - Phone:772-388-6400
Mailing Address - Fax:
Practice Address - Street 1:621 SEBASTIAN BLVD
Practice Address - Street 2:B
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-4309
Practice Address - Country:US
Practice Address - Phone:772-388-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN166401223E0200X
FLDN169781223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty