Healthcare Provider Details

I. General information

NPI: 1548390412
Provider Name (Legal Business Name): KEITH CASELLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S BROADWAY ST
SPRING VALLEY MN
55975-1227
US

IV. Provider business mailing address

101 S BROADWAY ST
SPRING VALLEY MN
55975-1227
US

V. Phone/Fax

Practice location:
  • Phone: 507-346-7281
  • Fax:
Mailing address:
  • Phone: 507-346-7281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11663
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: