Provider Demographics
NPI:1891142832
Name:GREAN, CASSANDRA L (DDS)
Entity Type:Individual
Prefix:DR
First Name:CASSANDRA
Middle Name:L
Last Name:GREAN
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 1:9630 GROVE CIR N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-3464
Mailing Address - Country:US
Mailing Address - Phone:763-420-5484
Mailing Address - Fax:
Practice Address - Street 1:9630 GROVE CIR N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-3464
Practice Address - Country:US
Practice Address - Phone:763-420-5484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13694122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist