Provider Demographics
NPI:1992729271
Name:KASSAB, JUAN CARLOS (DMD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:KASSAB
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 1:118 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANASTOTA
Mailing Address - State:NY
Mailing Address - Zip Code:13032-1234
Mailing Address - Country:US
Mailing Address - Phone:315-697-9287
Mailing Address - Fax:315-697-4038
Practice Address - Street 1:118 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CANASTOTA
Practice Address - State:NY
Practice Address - Zip Code:13032-1234
Practice Address - Country:US
Practice Address - Phone:315-697-9287
Practice Address - Fax:315-697-4038
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0443351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice