Provider Demographics
NPI:1043395809
Name:KHOURY, GHASSAN A (DMD,MPH,PC)
Entity Type:Individual
Prefix:DR
First Name:GHASSAN
Middle Name:A
Last Name:KHOURY
Suffix:
Gender:M
Credentials:DMD,MPH,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 COLLEEN DR
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347-1663
Mailing Address - Country:US
Mailing Address - Phone:508-947-0111
Mailing Address - Fax:
Practice Address - Street 1:12 COLLEEN DR
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MA
Practice Address - Zip Code:02347-1663
Practice Address - Country:US
Practice Address - Phone:508-947-0111
Practice Address - Fax:508-947-9815
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA204111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0202690Medicaid
NY02329784Medicaid
NH30303081Medicaid
MA0202690Medicaid