Provider Demographics
NPI:1306221221
Name:MUALLA, ALI
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:MUALLA
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 1:874 STREY LN APT 565
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-4319
Mailing Address - Country:US
Mailing Address - Phone:510-240-2365
Mailing Address - Fax:
Practice Address - Street 1:20401 STILLHOUSE BRANCH PL
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-5154
Practice Address - Country:US
Practice Address - Phone:510-240-2365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-21
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31156122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist