Healthcare Provider Details

I. General information

NPI: 1225052343
Provider Name (Legal Business Name): MICHAEL W MOFFITT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 W BROADWAY ST
EAGLE GROVE IA
50533-1704
US

IV. Provider business mailing address

422 W BROADWAY ST
EAGLE GROVE IA
50533-1704
US

V. Phone/Fax

Practice location:
  • Phone: 515-448-4852
  • Fax: 515-448-3533
Mailing address:
  • Phone: 515-448-4852
  • Fax: 515-448-3533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number6102
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: