Healthcare Provider Details

I. General information

NPI: 1912818626
Provider Name (Legal Business Name): CASSIDY JEAN DARRAGH
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N CLARE AVE
HARRISON MI
48625-8176
US

IV. Provider business mailing address

22211 BEECH ST
DEARBORN MI
48124-2703
US

V. Phone/Fax

Practice location:
  • Phone: 989-630-0760
  • Fax:
Mailing address:
  • Phone: 313-590-6989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901603302
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: