Provider Demographics
NPI:1982729091
Name:GRANT BLVD DENTAL PLLC
Entity Type:Organization
Organization Name:GRANT BLVD DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:KASSAB
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:315-472-3414
Mailing Address - Street 1:118 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANASTOTA
Mailing Address - State:NY
Mailing Address - Zip Code:13032-1234
Mailing Address - Country:US
Mailing Address - Phone:315-697-9287
Mailing Address - Fax:
Practice Address - Street 1:1500 GRANT BLVD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13208
Practice Address - Country:US
Practice Address - Phone:315-472-3414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04433511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========OtherEMPLOYER IDENTIFICATION #