=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295894590
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSSELL N MOSHER DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2006
-----------------------------------------------------
Last Update Date | 10/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1320 ALVERSER PLZ
-----------------------------------------------------
City | MIDLOTHIAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23113-2604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-379-6971
-----------------------------------------------------
Fax | 804-379-2796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1320 ALVERSER PLZ
-----------------------------------------------------
City | MIDLOTHIAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23113-2604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-379-6971
-----------------------------------------------------
Fax | 804-379-2796
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RUSSELL N MOSHER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 804-379-6971
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 0401007113
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------