MEDICARE: KEVIN M. LASSITER, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0700X	Prosthodontics

General Provider Information

NPI Number	:	1427916246
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEVIN M. LASSITER, PLLC

Provider Business Mailing Address
First Line	:	3160 E FOX ST
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85213-5418
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11130 N TATUM BLVD STE 103
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-1675
Country	:	US
Telephone Number	:	602-956-2260
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KEVIN LASSITER
Credential	:	DMD
Telephone Number	:	762-444-1061

Provider Enumeration Date	:	01/12/2026
Last Update Date	:	01/12/2026

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