MEDICARE: DR. NEZAR AHMED KASSEM D.D.S.

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	019025115	IL
2	1223G0001X	General Practice Dentistry	019025115	IL

General Provider Information

NPI Number	:	1700975653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NEZAR AHMED KASSEM D.D.S.

Provider Business Mailing Address
First Line	:	1314 RIDGEFIELD DR
Second Line	:
City	:	MAHOMET
State	:	IL
Zip	:	61853-7629
Country	:	US
Telephone Number	:	217-417-6683
Fax Number	:

Provider Business Practice Location Address
First Line	:	109 N WILLIAMSBURG DR
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61704-3528
Country	:	US
Telephone Number	:	309-662-3123
Fax Number	:	309-661-0798

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

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	02/21/2025

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