Provider Demographics
NPI:1902900038
Name:MUSSO, MICHAEL ALLEN (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLEN
Last Name:MUSSO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 W CENTERVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75041
Mailing Address - Country:US
Mailing Address - Phone:972-840-8477
Mailing Address - Fax:972-840-0505
Practice Address - Street 1:513 W CENTERVILLE ROAD
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75041
Practice Address - Country:US
Practice Address - Phone:972-840-8477
Practice Address - Fax:972-840-0505
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16290122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84D834OtherBCBS