Healthcare Provider Details

I. General information

NPI: 1679211049
Provider Name (Legal Business Name): SAMUEL DEAN MOSS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W WADE HAMPTON BLVD
GREER SC
29650-1243
US

IV. Provider business mailing address

400 MEMORIAL DRIVE EXT STE 400
GREER SC
29651-1850
US

V. Phone/Fax

Practice location:
  • Phone: 864-244-1494
  • Fax:
Mailing address:
  • Phone: 864-282-1935
  • Fax: 864-751-6387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDGD.10180
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: