Provider Demographics
NPI:1861654691
Name:GHASSAN KHOURY DMD PC
Entity Type:Organization
Organization Name:GHASSAN KHOURY DMD PC
Other - Org Name:KAPPA DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GHASSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHOURY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-666-4444
Mailing Address - Street 1:402 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-3823
Mailing Address - Country:US
Mailing Address - Phone:617-666-4444
Mailing Address - Fax:617-666-1113
Practice Address - Street 1:402 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-3823
Practice Address - Country:US
Practice Address - Phone:617-666-4444
Practice Address - Fax:617-666-1113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20411122300000X
MA20622122300000X
MA20871122300000X
MA203771223E0200X
MA219221223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX11554OtherBLUE CROSS BLUE SHIELD