Provider Demographics
NPI:1851521918
Name:CASA GRANDE IMPRESSIONS II, LLC
Entity Type:Organization
Organization Name:CASA GRANDE IMPRESSIONS II, LLC
Other - Org Name:IMPRESSIONS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:BRANDON
Authorized Official - Last Name:WETTSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-814-8888
Mailing Address - Street 1:442 W KORTSEN RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85222-5913
Mailing Address - Country:US
Mailing Address - Phone:520-374-2400
Mailing Address - Fax:520-374-2500
Practice Address - Street 1:442 W KORTSEN RD
Practice Address - Street 2:SUITE 104
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-5913
Practice Address - Country:US
Practice Address - Phone:520-374-2400
Practice Address - Fax:520-374-2500
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMPRESSIONS DENTAL, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD77491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty