=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578774550
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RALPH A. NICASSIO D.D.S.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11936 IMPERIAL HWY
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90650-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-868-7768
-----------------------------------------------------
Fax | 562-863-2369
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11936 IMPERIAL HWY
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90650-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-868-7768
-----------------------------------------------------
Fax | 562-863-2369
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RALPH A. NICASSIO
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 562-868-7768
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | B33642
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------