Provider Demographics
NPI:1851020663
Name:AL-THWEIB, MUTASEM (DMD, BDS)
Entity Type:Individual
Prefix:
First Name:MUTASEM
Middle Name:
Last Name:AL-THWEIB
Suffix:
Gender:M
Credentials:DMD, BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 S WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-7122
Mailing Address - Country:US
Mailing Address - Phone:219-874-7840
Mailing Address - Fax:
Practice Address - Street 1:1431 S WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7122
Practice Address - Country:US
Practice Address - Phone:219-874-7840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013800A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist