Provider Demographics
NPI:1942535091
Name:CASSANDRA G. BRACKETT, D.D.S.,P.C.
Entity Type:Organization
Organization Name:CASSANDRA G. BRACKETT, D.D.S.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:G
Authorized Official - Last Name:BRACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:404-289-3060
Mailing Address - Street 1:3300 MEMORIAL DR
Mailing Address - Street 2:SUITE D-3
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-2700
Mailing Address - Country:US
Mailing Address - Phone:404-289-3060
Mailing Address - Fax:404-288-6080
Practice Address - Street 1:3300 MEMORIAL DR
Practice Address - Street 2:SUITE D-3
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-2700
Practice Address - Country:US
Practice Address - Phone:404-289-3060
Practice Address - Fax:404-288-6080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-07
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0010117261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000310318CMedicaid