Healthcare Provider Details

I. General information

NPI: 1104308030
Provider Name (Legal Business Name): MOSS ORTHODONTICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 YELLOWSTONE AVE STE B
CODY WY
82414-9366
US

IV. Provider business mailing address

613 YELLOWSTONE AVE STE B
CODY WY
82414-9366
US

V. Phone/Fax

Practice location:
  • Phone: 307-587-9009
  • Fax:
Mailing address:
  • Phone: 307-587-9009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1133
License Number StateWY

VIII. Authorized Official

Name: MATHEW MOSS
Title or Position: OWNER
Credential: DDS, MS
Phone: 307-587-9009