Healthcare Provider Details

I. General information

NPI: 1033109186
Provider Name (Legal Business Name): PHILIP D MOSES DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 08/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 W COLLEGE ST
LAKE CHARLES LA
70605-1521
US

IV. Provider business mailing address

631 W COLLEGE ST
LAKE CHARLES LA
70605-1521
US

V. Phone/Fax

Practice location:
  • Phone: 337-474-9057
  • Fax: 337-474-9444
Mailing address:
  • Phone: 337-474-2563
  • Fax: 337-474-9444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3442
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: