Healthcare Provider Details

I. General information

NPI: 1194807545
Provider Name (Legal Business Name): MIRRIAL JANE MOSES D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1039 11TH ST
AUGUSTA GA
30901-2873
US

IV. Provider business mailing address

1039 11TH ST
AUGUSTA GA
30901-2873
US

V. Phone/Fax

Practice location:
  • Phone: 706-722-4008
  • Fax: 706-722-8833
Mailing address:
  • Phone: 706-722-4008
  • Fax: 706-722-8833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN010270
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: