Provider Demographics
NPI:1619397908
Name:INNABI, MOUSA
Entity Type:Individual
Prefix:
First Name:MOUSA
Middle Name:
Last Name:INNABI
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 1:944 N BROADWAY STE 105
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-1315
Mailing Address - Country:US
Mailing Address - Phone:914-327-4300
Mailing Address - Fax:914-327-4303
Practice Address - Street 1:944 N BROADWAY STE 105
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1315
Practice Address - Country:US
Practice Address - Phone:914-327-4300
Practice Address - Fax:914-327-4303
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0578901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice