MEDICARE: DR. GREGG LOUIS KASSAN 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	1223G0001X	General Practice Dentistry	0401-007927	VA

General Provider Information

NPI Number	:	1861665903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGG LOUIS KASSAN D.D.S.

Provider Business Mailing Address
First Line	:	5077 WATERWAY DR
Second Line	:
City	:	MONTCLAIR
State	:	VA
Zip	:	22025-1259
Country	:	US
Telephone Number	:	703-897-0463
Fax Number	:	703-897-1155

Provider Business Practice Location Address
First Line	:	5077 WATERWAY DR
Second Line	:
City	:	MONTCLAIR
State	:	VA
Zip	:	22025-1259
Country	:	US
Telephone Number	:	703-897-0463
Fax Number	:	703-897-1155

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

Provider Enumeration Date	:	04/09/2008
Last Update Date	:	04/09/2008

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