Healthcare Provider Details

I. General information

NPI: 1497000178
Provider Name (Legal Business Name): GLEN T. CASTO DDS, MDS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 SEBASTIAN BLVD B
SEBASTIAN FL
32958-4309
US

IV. Provider business mailing address

621 SEBASTIAN BLVD B
SEBASTIAN FL
32958-4309
US

V. Phone/Fax

Practice location:
  • Phone: 772-388-6400
  • Fax:
Mailing address:
  • Phone: 772-388-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN16640
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN16978
License Number StateFL

VIII. Authorized Official

Name: GLEN CASTO
Title or Position: OWNER
Credential:
Phone: 772-388-6400