Provider Demographics
NPI:1588674485
Name:KASIAH, ANDREA T
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:T
Last Name:KASIAH
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 1:2774 ELK LN
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-9114
Mailing Address - Country:US
Mailing Address - Phone:541-471-7062
Mailing Address - Fax:541-471-8539
Practice Address - Street 1:934 NE 8TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1641
Practice Address - Country:US
Practice Address - Phone:541-471-7062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH3886124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist