=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114047867
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JULIE DIANE CASSAIDY D.D.S., M.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 707 5TH ST SUITE 102
-----------------------------------------------------
City | AMES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50010-5979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-232-2152
-----------------------------------------------------
Fax | 515-232-2153
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3200 KINGMAN RD
-----------------------------------------------------
City | AMES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50014-3941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-292-5762
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 7768
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------