MEDICARE: KASSILEY ADRIANE DE FARIA DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	STUDENT	GA

General Provider Information

NPI Number	:	1639004633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KASSILEY ADRIANE DE FARIA DDS

Provider Business Mailing Address
First Line	:	1632 WILDWOOD RD
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30062-4051
Country	:	US
Telephone Number	:	678-431-8110
Fax Number	:

Provider Business Practice Location Address
First Line	:	910 GUADALUPE ST STE A
Second Line	:
City	:	LAREDO
State	:	TX
Zip	:	78040-5280
Country	:	US
Telephone Number	:	956-884-4840
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2026
Last Update Date	:	06/12/2026

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