Healthcare Provider Details

I. General information

NPI: 1639004633
Provider Name (Legal Business Name): KASSILEY ADRIANE DE FARIA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 GUADALUPE ST STE A
LAREDO TX
78040-5280
US

IV. Provider business mailing address

1632 WILDWOOD RD
MARIETTA GA
30062-4051
US

V. Phone/Fax

Practice location:
  • Phone: 956-884-4840
  • Fax:
Mailing address:
  • Phone: 678-431-8110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number42965
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: