Healthcare Provider Details

I. General information

NPI: 1265594535
Provider Name (Legal Business Name): DAVID K MOOSE D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 FREDERICK ST
CUMBERLAND MD
21502-1037
US

IV. Provider business mailing address

228 BALTIMORE AVE
CUMBERLAND MD
21502-2402
US

V. Phone/Fax

Practice location:
  • Phone: 301-722-3205
  • Fax:
Mailing address:
  • Phone: 240-527-3004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number13679
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: