Provider Demographics
NPI:1467818500
Name:JAMAL KUSSAD LLC
Entity Type:Organization
Organization Name:JAMAL KUSSAD LLC
Other - Org Name:DR. J. ALEXANDER KUSSAD, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMAL
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:KUSSAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-726-6107
Mailing Address - Street 1:1901 NE 162ND AVE
Mailing Address - Street 2:SUITE D-112
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-3009
Mailing Address - Country:US
Mailing Address - Phone:360-726-6107
Mailing Address - Fax:360-726-6105
Practice Address - Street 1:1901 NE 162ND AVE
Practice Address - Street 2:SUITE D-112
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-3009
Practice Address - Country:US
Practice Address - Phone:360-726-6107
Practice Address - Fax:360-726-6105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60457891261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental