Healthcare Provider Details

I. General information

NPI: 1730387655
Provider Name (Legal Business Name): LEE DANIEL CASEY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 S BROAD ST
LIBERTY MS
39645-8059
US

IV. Provider business mailing address

PO BOX 657
LIBERTY MS
39645-0657
US

V. Phone/Fax

Practice location:
  • Phone: 601-657-5877
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3412-07
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: