Healthcare Provider Details

I. General information

NPI: 1114319845
Provider Name (Legal Business Name): KASEY WILLIAM TEA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2015
Last Update Date: 03/30/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RHEINLAND-PFALZ DHA CMR 402 UNIT 33301
APO AE
09180
US

IV. Provider business mailing address

800 E 30TH ST SUITE 3
FARMINGTON NM
87401-9407
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-7261
  • Fax:
Mailing address:
  • Phone: 505-327-9161
  • Fax: 505-326-6657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00203017
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: