Provider Demographics
NPI:1356480156
Name:MOUSALLY, EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:MOUSALLY
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 1:23525 GOLDEN SPRINGS DR
Mailing Address - Street 2:SUITE C.
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-2175
Mailing Address - Country:US
Mailing Address - Phone:909-860-9399
Mailing Address - Fax:
Practice Address - Street 1:23525 GOLDEN SPRINGS DR
Practice Address - Street 2:SUITE C.
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-2175
Practice Address - Country:US
Practice Address - Phone:909-860-9399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA035303122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist