Provider Demographics
NPI:1568019479
Name:VELAZQUEZ, CASSI
Entity Type:Individual
Prefix:
First Name:CASSI
Middle Name:
Last Name:VELAZQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 STERNBERG AVE
Mailing Address - Street 2:
Mailing Address - City:FORT EUSTIS
Mailing Address - State:VA
Mailing Address - Zip Code:23604-1526
Mailing Address - Country:US
Mailing Address - Phone:757-314-7944
Mailing Address - Fax:
Practice Address - Street 1:649 NEW GUINEA RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-8124
Practice Address - Country:US
Practice Address - Phone:757-422-7077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS042444122300000X
VA0401417274122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1568019479OtherMILITARY
VA1568019479Medicaid