Provider Demographics
NPI:1588017883
Name:WIECZERZA, CASSANDRA LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CASSANDRA
Middle Name:LYNN
Last Name:WIECZERZA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:CASSANDRA
Other - Middle Name:LYNN
Other - Last Name:WEBSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:9625 PROMINENT PT STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80924-5005
Mailing Address - Country:US
Mailing Address - Phone:719-495-5748
Mailing Address - Fax:
Practice Address - Street 1:9625 PROMINENT PT STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80924-5005
Practice Address - Country:US
Practice Address - Phone:719-666-3579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2023-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600750390200000X
TX00320361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program