Provider Demographics
NPI:1962573816
Name:KASSAK, BILAL (DMD)
Entity type:Individual
Prefix:DR
First Name:BILAL
Middle Name:
Last Name:KASSAK
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 1:1518 WALNUT ST STE 400
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-3403
Mailing Address - Country:US
Mailing Address - Phone:215-317-7625
Mailing Address - Fax:215-772-0271
Practice Address - Street 1:1518 WALNUT ST STE 400
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3403
Practice Address - Country:US
Practice Address - Phone:215-317-7625
Practice Address - Fax:215-772-0271
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS031403-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001823934Medicaid
PA001823934Medicaid