Provider Demographics
NPI:1043621493
Name:LASSITER, KEVIN (DMD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:LASSITER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 WARRIOR RD
Mailing Address - Street 2:BLDG 2115
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:343 WARRIOR RD
Practice Address - Street 2:BUILDING 2115
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314
Practice Address - Country:US
Practice Address - Phone:912-767-1536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-45211223P0700X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist