=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821420092
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANNY MOOSA D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2013
-----------------------------------------------------
Last Update Date | 01/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4091 POWELL RD SUITE 1
-----------------------------------------------------
City | POWELL
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43065-7372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-659-0018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4091 POWELL RD SUITE 1
-----------------------------------------------------
City | POWELL
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43065-7372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-659-0018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 30.024288
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS040140
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------