Healthcare Provider Details

I. General information

NPI: 1588745228
Provider Name (Legal Business Name): JEFFREY VICTOR MOFFETT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 BAYSHORE BLVD 805
TAMPA FL
33606-2328
US

IV. Provider business mailing address

275 BAYSHORE BLVD 805
TAMPA FL
33606-2328
US

V. Phone/Fax

Practice location:
  • Phone: 305-725-2315
  • Fax:
Mailing address:
  • Phone: 305-725-2315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN15450
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: