=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932184199
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOUAWIA GHIBA DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 435 GRISWOLD RD
-----------------------------------------------------
City | ELYRIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44035-2304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-871-0948
-----------------------------------------------------
Fax | 440-324-9454
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 452 OAKMOOR RD
-----------------------------------------------------
City | BAY VILLAGE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44140-2521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-871-0948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 20505
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------