Healthcare Provider Details

I. General information

NPI: 1679026108
Provider Name (Legal Business Name): CASSANDRA DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 08/05/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COMMANDING OFFICER 100 BREWSTER BLVD
CAMP LEJEUNE NC
28547
US

IV. Provider business mailing address

BLDG 1040 WHEATHON AVE
WIESBADEN HESSEN
65205
DE

V. Phone/Fax

Practice location:
  • Phone: 910-451-2208
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD012132
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: