Provider Demographics
NPI:1073689204
Name:KUSSAD, JAMAL ALEXANDER (DDS)
Entity Type:Individual
Prefix:MR
First Name:JAMAL
Middle Name:ALEXANDER
Last Name:KUSSAD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 85
Mailing Address - Street 2:
Mailing Address - City:LYNDONVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05851-0085
Mailing Address - Country:US
Mailing Address - Phone:802-427-3323
Mailing Address - Fax:802-427-3332
Practice Address - Street 1:282 PINEHURST ST
Practice Address - Street 2:
Practice Address - City:LYNDONVILLE
Practice Address - State:VT
Practice Address - Zip Code:05851
Practice Address - Country:US
Practice Address - Phone:802-427-3323
Practice Address - Fax:802-427-3332
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX218551223G0001X
VT016.01339721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT6708822Medicaid
VT1073689204OtherID NUMBER