Provider Demographics
NPI:1679664510
Name:CASSIS, BRUCE L (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:L
Last Name:CASSIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 LIVELY ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-1148
Mailing Address - Country:US
Mailing Address - Phone:304-574-0424
Mailing Address - Fax:304-574-2102
Practice Address - Street 1:138 LIVELY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-1148
Practice Address - Country:US
Practice Address - Phone:304-574-0424
Practice Address - Fax:304-574-2102
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2530122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0136422000Medicaid