Healthcare Provider Details

I. General information

NPI: 1053495366
Provider Name (Legal Business Name): MARK A MOXLEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 11/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2981 N. WEBB RD.
WICHITA KS
67226
US

IV. Provider business mailing address

2981 N. WEBB RD.
WICHITA KS
67226
US

V. Phone/Fax

Practice location:
  • Phone: 316-685-2731
  • Fax: 316-685-6946
Mailing address:
  • Phone: 316-685-2731
  • Fax: 316-685-6946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5645
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: