Healthcare Provider Details

I. General information

NPI: 1902902208
Provider Name (Legal Business Name): BRETT EDDIS MOOSO D.D.S.,M.S.,P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 E 17TH ST
IDAHO FALLS ID
83404-6269
US

IV. Provider business mailing address

1410 E 17TH ST
IDAHO FALLS ID
83404-6269
US

V. Phone/Fax

Practice location:
  • Phone: 208-522-4552
  • Fax: 208-522-4555
Mailing address:
  • Phone: 208-522-4552
  • Fax: 208-522-4555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD-3029-OR
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: