Provider Demographics
NPI:1245521228
Name:GLEN T. CASTO DDS,MDS,PA
Entity type:Organization
Organization Name:GLEN T. CASTO DDS,MDS,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:POPPELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-388-6400
Mailing Address - Street 1:621 SEBASTIAN BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-4309
Mailing Address - Country:US
Mailing Address - Phone:772-388-6400
Mailing Address - Fax:772-388-6446
Practice Address - Street 1:621 SEBASTIAN BOULEVARD
Practice Address - Street 2:SUITE B
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958
Practice Address - Country:US
Practice Address - Phone:772-388-6400
Practice Address - Fax:772-388-6446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN166401223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty