Healthcare Provider Details

I. General information

NPI: 1518986314
Provider Name (Legal Business Name): MATHEW A MOSS D.D.S., P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1817 17TH ST
CODY WY
82414-4701
US

IV. Provider business mailing address

1817 17TH ST
CODY WY
82414-4701
US

V. Phone/Fax

Practice location:
  • Phone: 307-587-9009
  • Fax: 307-587-9444
Mailing address:
  • Phone: 307-587-9009
  • Fax: 307-587-9444

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:
Title or Position:
Credential:
Phone: