Healthcare Provider Details

I. General information

NPI: 1073173050
Provider Name (Legal Business Name): MARIAH MOXLEY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N TYLER RD STE 2
WICHITA KS
67212-3249
US

IV. Provider business mailing address

15455 E 13TH ST N
WICHITA KS
67230-7572
US

V. Phone/Fax

Practice location:
  • Phone: 316-722-2596
  • Fax:
Mailing address:
  • Phone: 316-304-8884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number61626
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: