Basic Information
| Provider Information | |||||||||
| NPI: | 1437598976 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENNEN | ||||||||
| FirstName: | CASSIDY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275 S ASPEN ST BLDG 600 | ||||||||
| Address2: | |||||||||
| City: | BUCKLEY AFB | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800119562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7208476543 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 TWINING ST BLDG 760 | ||||||||
| Address2: | |||||||||
| City: | MAXWELL AFB | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361126027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3349535143 | ||||||||
| FaxNumber: | 3349538607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2013 | ||||||||
| LastUpdateDate: | 09/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DS039677 | PA | Y | Dental Providers | Dentist | General Practice |
No ID Information.