MEDICARE: DR. HADEEL AL-KASSAB 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	122300000X	Dentist	2901020277	MI
2	1223G0001X	General Practice Dentistry	2013043437	MO

General Provider Information

NPI Number	:	1053625079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HADEEL AL-KASSAB DDS

Provider Business Mailing Address
First Line	:	12000 BELLEFONTAINE RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63138-1903
Country	:	US
Telephone Number	:	314-741-5133
Fax Number	:	314-741-3161

Provider Business Practice Location Address
First Line	:	12000 BELLEFONTAINE RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63138-1903
Country	:	US
Telephone Number	:	314-741-5133
Fax Number	:	314-741-3161

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

Provider Enumeration Date	:	08/02/2010
Last Update Date	:	09/30/2021

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