Provider Demographics
NPI:1568926046
Name:CASEY FAMILY DENTAL DDS, PS
Entity Type:Organization
Organization Name:CASEY FAMILY DENTAL DDS, PS
Other - Org Name:LIBERTY LAKE SMILE SOURCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHRISTOPHERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-927-9279
Mailing Address - Street 1:22011 E COUNTRY VISTA DR STE 201
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-5242
Mailing Address - Country:US
Mailing Address - Phone:509-927-9279
Mailing Address - Fax:509-927-9278
Practice Address - Street 1:22011 E COUNTRY VISTA DR STE 201
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-5242
Practice Address - Country:US
Practice Address - Phone:509-927-9279
Practice Address - Fax:509-927-9278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-29
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty