Healthcare Provider Details

I. General information

NPI: 1720490303
Provider Name (Legal Business Name): CASSANDRA CAO D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14435 NORTHLAND DR
BIG RAPIDS MI
49307-2368
US

IV. Provider business mailing address

1 WATER ST SUITE 200
BOYNE CITY MI
49712-1810
US

V. Phone/Fax

Practice location:
  • Phone: 231-796-3617
  • Fax:
Mailing address:
  • Phone: 231-154-7763
  • Fax: 231-582-2967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901021233
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: