MEDICARE: JOHN W MOSHER 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	1803	ND

General Provider Information

NPI Number	:	1780776112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN W MOSHER DDS

Provider Business Mailing Address
First Line	:	PO BOX 6002
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58206-6002
Country	:	US
Telephone Number	:	701-780-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2812 17TH AVE S STE F
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-4048
Country	:	US
Telephone Number	:	701-746-1400
Fax Number	:

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

Provider Enumeration Date	:	09/30/2006
Last Update Date	:	07/08/2007

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