Provider Demographics
NPI:1871777391
Name:HAILU, KASSAHUN H (DDS)
Entity type:Individual
Prefix:
First Name:KASSAHUN
Middle Name:H
Last Name:HAILU
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11300 ROCKVILLE PIKE STE 711
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3011
Mailing Address - Country:US
Mailing Address - Phone:301-770-0123
Mailing Address - Fax:301-770-2877
Practice Address - Street 1:11300 ROCKVILLE PIKE STE 711
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3011
Practice Address - Country:US
Practice Address - Phone:303-770-0123
Practice Address - Fax:301-770-2877
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD122671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD013173300Medicaid