Provider Demographics
NPI:1932927209
Name:MOUSAVI, MOHAMMAD
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:MOUSAVI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5106 DEER CREEK PL
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-5052
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5601 BRODIE LN STE 1325
Practice Address - Street 2:
Practice Address - City:SUNSET VALLEY
Practice Address - State:TX
Practice Address - Zip Code:78745-0010
Practice Address - Country:US
Practice Address - Phone:512-354-3920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX410101223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics