Provider Demographics
NPI:1790338853
Name:PHAGAN, CASSIDY VERONICA (DDS)
Entity Type:Individual
Prefix:DR
First Name:CASSIDY
Middle Name:VERONICA
Last Name:PHAGAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2527 N SPRINGFIELD AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-1028
Mailing Address - Country:US
Mailing Address - Phone:847-721-7628
Mailing Address - Fax:
Practice Address - Street 1:719 BARRON BLVD
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-3314
Practice Address - Country:US
Practice Address - Phone:847-986-6724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL00122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist