Healthcare Provider Details

I. General information

NPI: 1629342530
Provider Name (Legal Business Name): NATHAN A MOELLER DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2012
Last Update Date: 08/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E 20TH AVE
TORRINGTON WY
82240
US

IV. Provider business mailing address

211 E 20TH AVE
TORRINGTON WY
82240-2813
US

V. Phone/Fax

Practice location:
  • Phone: 307-886-4300
  • Fax:
Mailing address:
  • Phone: 307-886-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number10070
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: