Provider Demographics
NPI:1265166599
Name:MOUSA-AQRAWI, MARYSOUL
Entity type:Individual
Prefix:
First Name:MARYSOUL
Middle Name:
Last Name:MOUSA-AQRAWI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4777 ASPENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-2945
Mailing Address - Country:US
Mailing Address - Phone:586-277-2921
Mailing Address - Fax:
Practice Address - Street 1:4777 ASPENWOOD DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-2945
Practice Address - Country:US
Practice Address - Phone:586-277-2921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016014801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice