Provider Demographics
NPI:1023469210
Name:MOUSA, CHRISTINE (DMD)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:MOUSA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:CHRISTIN
Other - Middle Name:
Other - Last Name:GIRGIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:811 SHANNON DR
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-8999
Mailing Address - Country:US
Mailing Address - Phone:503-380-6928
Mailing Address - Fax:
Practice Address - Street 1:6075 CLEVELAND CIR
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-2378
Practice Address - Country:US
Practice Address - Phone:219-769-6316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-29
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012520A1223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice