Provider Demographics
NPI:1841712668
Name:MOOSAVI, MUJTABA HUSSAIN (DMD)
Entity type:Individual
Prefix:
First Name:MUJTABA
Middle Name:HUSSAIN
Last Name:MOOSAVI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 AMBERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08048-4309
Mailing Address - Country:US
Mailing Address - Phone:609-634-0192
Mailing Address - Fax:
Practice Address - Street 1:77 JULIUSTOWN RD
Practice Address - Street 2:
Practice Address - City:BROWNS MILLS
Practice Address - State:NJ
Practice Address - Zip Code:08015-3627
Practice Address - Country:US
Practice Address - Phone:609-531-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI026821001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice