Healthcare Provider Details

I. General information

NPI: 1124792585
Provider Name (Legal Business Name): DYLAN KASSENBROCK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2021
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4530 E MUIRWOOD DR STE 110
PHOENIX AZ
85048-7693
US

IV. Provider business mailing address

2910 N 3RD AVE # 200
PHOENIX AZ
85013-4434
US

V. Phone/Fax

Practice location:
  • Phone: 480-763-5808
  • Fax: 833-973-5420
Mailing address:
  • Phone: 602-406-3181
  • Fax: 855-973-5424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number012377
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: