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General NPI Number Information
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NPI Number | 1902902208
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Entity Type | Individual
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Provider Name | BRETT EDDIS MOOSO D.D.S.,M.S.,P.A.
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Gender | Male
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Dates
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Enumeration Date | 09/15/2006
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 1410 E 17TH ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404-6269
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Country | US
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Telephone | 208-522-4552
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Fax | 208-522-4555
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Provider Business Mailing Address
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Address Line | 1410 E 17TH ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404-6269
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Country | US
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Telephone | 208-522-4552
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Fax | 208-522-4555
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | D-3029-OR
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License Number State | ID
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