MEDICARE: DR. MAI KOUSSA 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	0401410151	VA

General Provider Information

NPI Number	:	1518174069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAI KOUSSA DDS

Provider Business Mailing Address
First Line	:	7233 COMMERCE ST
Second Line	:
City	:	SPRINGFIELD
State	:	VA
Zip	:	22150-3411
Country	:	US
Telephone Number	:	703-644-7300
Fax Number	:	703-866-4319

Provider Business Practice Location Address
First Line	:	7233 COMMERCE ST
Second Line	:
City	:	SPRINGFIELD
State	:	VA
Zip	:	22150-3411
Country	:	US
Telephone Number	:	703-644-7300
Fax Number	:	703-866-4319

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

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	07/08/2007

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