Provider Demographics
NPI:1659614410
Name:JACKLIS, GHASSAN ELIAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:GHASSAN
Middle Name:ELIAS
Last Name:JACKLIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11125 ROCKVILLE PIKE STE 204
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3142
Mailing Address - Country:US
Mailing Address - Phone:301-888-6666
Mailing Address - Fax:
Practice Address - Street 1:11125 ROCKVILLE PIKE STE 204
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3142
Practice Address - Country:US
Practice Address - Phone:301-888-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-30
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC10012561223G0001X
MD119911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0401413871OtherLICENSE
MD11991OtherLICENSE NUMBER