Provider Demographics
NPI:1033179577
Name:STACY, CASSANDRA LYNNE (DMD)
Entity type:Individual
Prefix:DR
First Name:CASSANDRA
Middle Name:LYNNE
Last Name:STACY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 CLIFF RD STE 100
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2486
Mailing Address - Country:US
Mailing Address - Phone:651-452-6933
Mailing Address - Fax:
Practice Address - Street 1:2130 CLIFF RD STE 100
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2486
Practice Address - Country:US
Practice Address - Phone:651-452-6933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND120521223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN116645000Medicaid