Provider Demographics
NPI:1730560467
Name:LASTOVICA, CAITLYN MARIE (DDS)
Entity type:Individual
Prefix:
First Name:CAITLYN
Middle Name:MARIE
Last Name:LASTOVICA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W 38TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4778
Mailing Address - Country:US
Mailing Address - Phone:308-632-5131
Mailing Address - Fax:
Practice Address - Street 1:210 W 38TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4778
Practice Address - Country:US
Practice Address - Phone:308-632-5131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7230122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist