Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 14900 | OH |
NPI | 1073564142 |
---|---|
Provider Name | Dr. Gerald H Kassoy |
First Address | Bexley, OH 43209-1831 |
Second Address | Reynoldsburg, OH 43068-2397 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/05/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0398627 | (05) | OH |
310961704-026 | CARESOURCE (01) | OH |