MEDICARE: DR. RUSSELL A SASSACK DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	13817	MI

General Provider Information

NPI Number	:	1720031115
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSSELL A SASSACK DDS

Provider Business Mailing Address
First Line	:	43771 VAN DYKE AVE
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48314-2445
Country	:	US
Telephone Number	:	586-323-2273
Fax Number	:	586-323-9460

Provider Business Practice Location Address
First Line	:	43771 VAN DYKE AVE
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48314-2445
Country	:	US
Telephone Number	:	586-323-2273
Fax Number	:	586-323-9460

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	10/25/2013

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