Healthcare Provider Details

I. General information

NPI: 1487220877
Provider Name (Legal Business Name): CASSADY RIDER DDS PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 05/27/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W MAIN ST
CHEROKEE IA
51012-1825
US

IV. Provider business mailing address

210 W MAIN ST
CHEROKEE IA
51012-1825
US

V. Phone/Fax

Practice location:
  • Phone: 712-225-0432
  • Fax:
Mailing address:
  • Phone: 712-225-0432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. CASSADY RIDER
Title or Position: OWNER
Credential: DDS
Phone: 712-225-0432