Healthcare Provider Details

I. General information

NPI: 1639242654
Provider Name (Legal Business Name): ANDREW JAMES CASSIDY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 FORUM DR
ROLLA MO
65401-2587
US

IV. Provider business mailing address

12655 GINGER LN
ROLLA MO
65401-6747
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-1821
  • Fax:
Mailing address:
  • Phone: 573-364-5684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number015886
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: