Provider Demographics
NPI:1255495685
Name:MOUSSALLI, RICHARD LEWIS (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LEWIS
Last Name:MOUSSALLI
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 1:115 S PHELPS ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:MI
Mailing Address - Zip Code:49045-1117
Mailing Address - Country:US
Mailing Address - Phone:269-423-4961
Mailing Address - Fax:269-423-8927
Practice Address - Street 1:115 S PHELPS ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:MI
Practice Address - Zip Code:49045-1117
Practice Address - Country:US
Practice Address - Phone:269-423-4961
Practice Address - Fax:269-423-8927
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010146481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1844602Medicaid