Healthcare Provider Details

I. General information

NPI: 1932194099
Provider Name (Legal Business Name): JEFFREY ALLEN MOELLER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12389 AUDRAIN ROAD 9931
MEXICO MO
65265-6260
US

IV. Provider business mailing address

12389 AUDRAIN ROAD 9931
MEXICO MO
65265-6260
US

V. Phone/Fax

Practice location:
  • Phone: 719-251-4947
  • Fax:
Mailing address:
  • Phone: 719-251-4947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD11669
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: