Provider Demographics
NPI:1063702223
Name:DASSOULAS, KASANDRA RAE
Entity type:Individual
Prefix:
First Name:KASANDRA
Middle Name:RAE
Last Name:DASSOULAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10810 CONNECTICUT AVE
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20895-2138
Mailing Address - Country:US
Mailing Address - Phone:301-929-7100
Mailing Address - Fax:
Practice Address - Street 1:10810 CONNECTICUT AVE
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2138
Practice Address - Country:US
Practice Address - Phone:434-326-7386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD83761208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery