MEDICARE: DR. WILLIAM GARDNER MOLL D.D.S.

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	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	12012169A	IN

General Provider Information

NPI Number	:	1558789891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM GARDNER MOLL D.D.S.

Provider Business Mailing Address
First Line	:	601 W US HIGHWAY 30
Second Line	:
City	:	SCHERERVILLE
State	:	IN
Zip	:	46375-2656
Country	:	US
Telephone Number	:	219-322-0501
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 W US HIGHWAY 30
Second Line	:
City	:	SCHERERVILLE
State	:	IN
Zip	:	46375-2656
Country	:	US
Telephone Number	:	219-322-0501
Fax Number	:

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

Provider Enumeration Date	:	04/03/2014
Last Update Date	:	11/26/2019

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