Provider Demographics
NPI:1821724220
Name:MOUSSA, SELVANA (DDS)
Entity Type:Individual
Prefix:
First Name:SELVANA
Middle Name:
Last Name:MOUSSA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 PULLMAN CAR DR APT 201
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-3378
Mailing Address - Country:US
Mailing Address - Phone:615-299-7917
Mailing Address - Fax:
Practice Address - Street 1:5628 CIRCA FISHHAWK BLVD
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-4218
Practice Address - Country:US
Practice Address - Phone:813-324-5795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN27205122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist