Provider Demographics
NPI:1942557830
Name:SUTHERLAND, CASEY D (DMD)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:D
Last Name:SUTHERLAND
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 405
Mailing Address - Street 2:
Mailing Address - City:MANSON
Mailing Address - State:WA
Mailing Address - Zip Code:98831-0405
Mailing Address - Country:US
Mailing Address - Phone:509-687-9221
Mailing Address - Fax:509-687-9201
Practice Address - Street 1:160 WAPATO WAY
Practice Address - Street 2:
Practice Address - City:MANSON
Practice Address - State:WA
Practice Address - Zip Code:98831
Practice Address - Country:US
Practice Address - Phone:509-687-9221
Practice Address - Fax:509-687-9201
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE605654981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1841746427OtherINSURANCE