Provider Demographics
NPI:1700455870
Name:SANDERS, CASEY DALE (DMD)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:DALE
Last Name:SANDERS
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 1:1871 SPANISH FORK WAY APT F308
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5627
Mailing Address - Country:US
Mailing Address - Phone:702-539-7353
Mailing Address - Fax:
Practice Address - Street 1:2275 S EAGLE RD STE 150
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5075
Practice Address - Country:US
Practice Address - Phone:208-888-2000
Practice Address - Fax:208-888-1571
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD53041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice