Healthcare Provider Details

I. General information

NPI: 1477873040
Provider Name (Legal Business Name): CASEY M. SLACK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2010
Last Update Date: 10/07/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
DAYTON OH
45433
US

IV. Provider business mailing address

1065 BOSTON ROAD
JOINT BASE ANDREWS MD
20762
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-0500
  • Fax:
Mailing address:
  • Phone: 240-857-5029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0401413693
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0442000128
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401413693
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: