Healthcare Provider Details

I. General information

NPI: 1063492502
Provider Name (Legal Business Name): CARL WAYNE DASSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4175 S ALAMO AVE
DM AFB AZ
85707-6097
US

IV. Provider business mailing address

6401 E SHEPHERD HLS
TUCSON AZ
85710-1124
US

V. Phone/Fax

Practice location:
  • Phone: 520-228-2600
  • Fax:
Mailing address:
  • Phone: 520-886-1823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6973
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: