MEDICARE: SELVANA MOUSSA DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN27205	FL

General Provider Information

NPI Number	:	1821724220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SELVANA MOUSSA DDS

Provider Business Mailing Address
First Line	:	3131 PULLMAN CAR DR APT 201
Second Line	:
City	:	VALRICO
State	:	FL
Zip	:	33594-3378
Country	:	US
Telephone Number	:	615-299-7917
Fax Number	:

Provider Business Practice Location Address
First Line	:	5628 CIRCA FISHHAWK BLVD
Second Line	:
City	:	LITHIA
State	:	FL
Zip	:	33547-4218
Country	:	US
Telephone Number	:	813-324-5795
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2022
Last Update Date	:	07/27/2022

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