Healthcare Provider Details

I. General information

NPI: 1639090947
Provider Name (Legal Business Name): MARIA MOUCHAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 OHIO ST
GREAT LAKES IL
60088-3155
US

IV. Provider business mailing address

908 LAKE HILL CT
FORT WAYNE IN
46845-2328
US

V. Phone/Fax

Practice location:
  • Phone: 765-283-5927
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number019.037143
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: