Provider Demographics
NPI:1598270993
Name:CASTANEDA FASSIOLI DENTAL CORP
Entity Type:Organization
Organization Name:CASTANEDA FASSIOLI DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:CASTANEDA FASSIOLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-716-7000
Mailing Address - Street 1:22706 ASPAN ST STE 602
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1603
Mailing Address - Country:US
Mailing Address - Phone:949-716-7000
Mailing Address - Fax:949-716-0600
Practice Address - Street 1:22706 ASPAN ST STE 602
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1603
Practice Address - Country:US
Practice Address - Phone:949-716-7000
Practice Address - Fax:949-716-0600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-07
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101094261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental