Healthcare Provider Details

I. General information

NPI: 1972129054
Provider Name (Legal Business Name): MOSHE DAVIDOVITCH DDS, MMSC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 JABOTINSKY STREET APT 3
TEL AVIV ISRAEL
6918400
IL

IV. Provider business mailing address

84 JABOTINSKY STREET APT 3
TEL AVIV ISRAEL
6918400
IL

V. Phone/Fax

Practice location:
  • Phone: 50-556-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN17488
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: