Provider Demographics
NPI:1639315377
Name:MUSTAPHA, INDRA Z (DDA, MS, PHD)
Entity Type:Individual
Prefix:
First Name:INDRA
Middle Name:Z
Last Name:MUSTAPHA
Suffix:
Gender:F
Credentials:DDA, MS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 MASSACHUSETTS AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20005-5302
Mailing Address - Country:US
Mailing Address - Phone:202-628-7979
Mailing Address - Fax:
Practice Address - Street 1:1221 MASSACHUSETTS AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20005-5302
Practice Address - Country:US
Practice Address - Phone:202-628-7979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-31
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD121381223P0300X
DCDEN5830122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0300XDental ProvidersDentistPeriodontics