Healthcare Provider Details

I. General information

NPI: 1790724938
Provider Name (Legal Business Name): MATTHEW BRADLEY CASEY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 BROADWAY ST SUITE # 107
EL CENTRO CA
92243-2337
US

IV. Provider business mailing address

1030 BROADWAY ST SUITE # 107
EL CENTRO CA
92243-2337
US

V. Phone/Fax

Practice location:
  • Phone: 760-337-7747
  • Fax: 760-337-6897
Mailing address:
  • Phone: 760-337-7747
  • Fax: 760-337-6897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number38656
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: