Healthcare Provider Details

I. General information

NPI: 1699759480
Provider Name (Legal Business Name): GREGORY GEORGE CASALONE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S 4TH ST
ELSBERRY MO
63343-1426
US

IV. Provider business mailing address

110 S 4TH ST
ELSBERRY MO
63343-1426
US

V. Phone/Fax

Practice location:
  • Phone: 573-898-5575
  • Fax:
Mailing address:
  • Phone: 573-898-5575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number12841
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: