MEDICARE: SARA WISAM KASSIM 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	1223G0001X	General Practice Dentistry	2901022185	MI
2	1223G0001X	General Practice Dentistry	33457	TX

General Provider Information

NPI Number	:	1932636107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARA WISAM KASSIM DDS

Provider Business Mailing Address
First Line	:	206 ALICANTE RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78257-1676
Country	:	US
Telephone Number	:	210-937-2840
Fax Number	:

Provider Business Practice Location Address
First Line	:	206 ALICANTE RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78257-1676
Country	:	US
Telephone Number	:	210-937-2840
Fax Number	:

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

Provider Enumeration Date	:	05/17/2017
Last Update Date	:	09/01/2020

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