Provider Demographics
NPI:1972699833
Name:NAM, KASIE Y (DDS)
Entity Type:Individual
Prefix:
First Name:KASIE
Middle Name:Y
Last Name:NAM
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 1:6117 N COLLEGE AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-1952
Mailing Address - Country:US
Mailing Address - Phone:317-256-3368
Mailing Address - Fax:317-257-5909
Practice Address - Street 1:6117 N COLLEGE AVE STE 1
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-1952
Practice Address - Country:US
Practice Address - Phone:317-256-3368
Practice Address - Fax:317-257-5909
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010943A1223G0001X
AZ57511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice