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NPI Code Detail

MEDICARE: DR. CHIA WAM MOUA DDS

MEDICARE: DR. CHIA WAM MOUA DDS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223G0001XGeneral Practice DentistryD13994MN

General Provider Information

NPI Number : 1104316801
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. CHIA WAM MOUA DDS
Provider Business Mailing Address
First Line : 1770 BLUEWATER LN
Second Line :
City : WOODBURY
State : MN
Zip : 55129-6236
Country : US
Telephone Number : 612-810-0978
Fax Number :
Provider Business Practice Location Address
First Line : 1670 BEAM AVE STE 204
Second Line :
City : MAPLEWOOD
State : MN
Zip : 55109-1227
Country : US
Telephone Number : 651-925-8416
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/17/2018
Last Update Date : 05/17/2018

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