Provider Demographics
NPI:1730319898
Name:MOUALLEM, MARC R (DDS)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:R
Last Name:MOUALLEM
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 1:1747 PENNSYLVANIA AVE NW
Mailing Address - Street 2:SUITE #140
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20006-4604
Mailing Address - Country:US
Mailing Address - Phone:202-833-3333
Mailing Address - Fax:301-907-9089
Practice Address - Street 1:1747 PENNSYLVANIA AVE NW
Practice Address - Street 2:SUITE #140
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20006-4604
Practice Address - Country:US
Practice Address - Phone:202-833-3333
Practice Address - Fax:301-907-9089
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN2697122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist