Healthcare Provider Details

I. General information

NPI: 1154431948
Provider Name (Legal Business Name): RYAN S MOXON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 WOOLSEY ROAD
HAMPTON GA
30228
US

IV. Provider business mailing address

98 WOOLSEY ROAD
HAMPTON GA
30228
US

V. Phone/Fax

Practice location:
  • Phone: 770-707-0025
  • Fax: 770-707-0093
Mailing address:
  • Phone: 770-707-0025
  • Fax: 770-707-0093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDNO11789
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: