Healthcare Provider Details

I. General information

NPI: 1952685570
Provider Name (Legal Business Name): GARY ANTHONY MOELLER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2011
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ELEVENTH AVE SUITE D-3
SHALIMAR FL
32579
US

IV. Provider business mailing address

1 ELEVENTH AVE SUITE D-3
SHALIMAR FL
32579
US

V. Phone/Fax

Practice location:
  • Phone: 850-651-6700
  • Fax: 850-609-0796
Mailing address:
  • Phone: 850-651-6700
  • Fax: 850-609-0796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN20806
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8010253-9922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: