1629083027 NPI number — DR. LAWRENCE EDWARD KOUSSA DDS

Table of content: DR. LAWRENCE EDWARD KOUSSA DDS (NPI 1629083027)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629083027 NPI number — DR. LAWRENCE EDWARD KOUSSA DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOUSSA
Provider First Name:
LAWRENCE
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KOUSSA
Provider Other First Name:
LARRY
Provider Other Middle Name:
EDWARD
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1629083027
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2102 N COUNTRY CLUB RD STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85716-2831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-327-6269
Provider Business Mailing Address Fax Number:
520-327-6632

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2102 N COUNTRY CLUB RD STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85716-2831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-327-6269
Provider Business Practice Location Address Fax Number:
520-327-6632
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3782 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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