Healthcare Provider Details

I. General information

NPI: 1922338730
Provider Name (Legal Business Name): MICHAEL V. CASEY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2009
Last Update Date: 12/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 N LARKIN AVE
JOLIET IL
60435-3456
US

IV. Provider business mailing address

1118 N LARKIN AVE
JOLIET IL
60435-3456
US

V. Phone/Fax

Practice location:
  • Phone: 815-725-4070
  • Fax: 815-725-4054
Mailing address:
  • Phone: 815-725-4070
  • Fax: 815-725-4054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021001362
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: