MEDICARE: PREMIER FAMILY DENTAL - WESTLAKE, KOUSSA, DDS INC

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

General Provider Information

NPI Number	:	1023033958
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER FAMILY DENTAL - WESTLAKE, KOUSSA, DDS INC

Provider Business Mailing Address
First Line	:	24803 DETROIT RD
Second Line	:	SUITE A
City	:	WESTLAKE
State	:	OH
Zip	:	44145-2553
Country	:	US
Telephone Number	:	440-835-5388
Fax Number	:	440-835-2101

Provider Business Practice Location Address
First Line	:	24803 DETROIT RD
Second Line	:	SUITE A
City	:	WESTLAKE
State	:	OH
Zip	:	44145-2553
Country	:	US
Telephone Number	:	440-835-5388
Fax Number	:	440-835-2101

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NADEEM KOUSSA
Credential	:	DDS
Telephone Number	:	440-835-5388

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	08/22/2020

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