Healthcare Provider Details

I. General information

NPI: 1730226333
Provider Name (Legal Business Name): MICHAEL MOGA LD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12400 SW ALLEN BLVD SUITE B
BEAVERTON OR
97005-4714
US

IV. Provider business mailing address

12400 SW ALLEN BLVD SUITE B
BEAVERTON OR
97005-4714
US

V. Phone/Fax

Practice location:
  • Phone: 503-643-6213
  • Fax:
Mailing address:
  • Phone: 503-643-6213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDT-DO-188851
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: