Provider Demographics
NPI:1962071894
Name:NASSER, MOUSTAPHA ALI (DDS)
Entity type:Individual
Prefix:DR
First Name:MOUSTAPHA
Middle Name:ALI
Last Name:NASSER
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 1:4601 CHOVIN ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4608
Mailing Address - Country:US
Mailing Address - Phone:313-485-3079
Mailing Address - Fax:
Practice Address - Street 1:15031 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3443
Practice Address - Country:US
Practice Address - Phone:313-582-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016010041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice