Provider Demographics
NPI:1457877821
Name:MOUREIDEN, BANA (DMD)
Entity type:Individual
Prefix:
First Name:BANA
Middle Name:
Last Name:MOUREIDEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2414 ELMDALE RD
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-4647
Mailing Address - Country:US
Mailing Address - Phone:352-540-5232
Mailing Address - Fax:
Practice Address - Street 1:11250 E 13 MILE RD STE 3
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2597
Practice Address - Country:US
Practice Address - Phone:586-574-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.025119122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist