Provider Demographics
NPI:1679059521
Name:MASSOUD, MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MASSOUD
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 1:128 LEAH CT
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08810-1348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:63 N LAKEVIEW DR STE 101
Practice Address - Street 2:
Practice Address - City:GIBBSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08026-1026
Practice Address - Country:US
Practice Address - Phone:856-784-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2019-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI027239001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice