Provider Demographics
NPI:1578743605
Name:KASSAB, KHAYRI
Entity Type:Individual
Prefix:DR
First Name:KHAYRI
Middle Name:
Last Name:KASSAB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30480 SHOREHAM ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-5368
Mailing Address - Country:US
Mailing Address - Phone:248-790-3738
Mailing Address - Fax:248-552-3777
Practice Address - Street 1:18161 W 12 MILE RD
Practice Address - Street 2:SUIT 2
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-2662
Practice Address - Country:US
Practice Address - Phone:248-552-0777
Practice Address - Fax:248-552-3777
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010192201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice