Provider Demographics
NPI:1841393360
Name:CASSIDY, KEVIN JOHN (DDS)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JOHN
Last Name:CASSIDY
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 1:585 TAHOE KEYS BLVD
Mailing Address - Street 2:STE 2
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150
Mailing Address - Country:US
Mailing Address - Phone:530-541-3772
Mailing Address - Fax:530-541-0330
Practice Address - Street 1:585 TAHOE KEYS BLVD
Practice Address - Street 2:STE 2
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150
Practice Address - Country:US
Practice Address - Phone:530-541-3772
Practice Address - Fax:530-541-0330
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37979122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist