Healthcare Provider Details

I. General information

NPI: 1275707747
Provider Name (Legal Business Name): MARK L MOSS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2008
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8636 N 59TH AVE
GLENDALE AZ
85302-5404
US

IV. Provider business mailing address

8636 N 59TH AVE
GLENDALE AZ
85302-5404
US

V. Phone/Fax

Practice location:
  • Phone: 623-937-3500
  • Fax:
Mailing address:
  • Phone: 623-937-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number27658
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD7452
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: