Healthcare Provider Details

I. General information

NPI: 1942557830
Provider Name (Legal Business Name): CASEY D SUTHERLAND DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2012
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 WAPATO WAY
MANSON WA
98831
US

IV. Provider business mailing address

PO BOX 405
MANSON WA
98831-0405
US

V. Phone/Fax

Practice location:
  • Phone: 509-687-9221
  • Fax: 509-687-9201
Mailing address:
  • Phone: 509-687-9221
  • Fax: 509-687-9201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE60565498
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: