Provider Demographics
NPI:1477873040
Name:SLACK, CASEY M (DDS)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:M
Last Name:SLACK
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 1:1065 BOSTON ROAD
Mailing Address - Street 2:
Mailing Address - City:JOINT BASE ANDREWS
Mailing Address - State:MD
Mailing Address - Zip Code:20762
Mailing Address - Country:US
Mailing Address - Phone:240-857-5029
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45433
Practice Address - Country:US
Practice Address - Phone:937-257-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413693122300000X, 1223G0001X
VA0442000128390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program