MEDICARE: HAITHAM MOSLY, DMD, A PROFESSIONAL CORPORATION

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
1	122300000X	Dentist	61008	CA

General Provider Information

NPI Number	:	1427435809
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAITHAM MOSLY, DMD, A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	1740 SANTA CLARA DR
Second Line	:	SUITE 100-B
City	:	ROSEVILLE
State	:	CA
Zip	:	95661-2921
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1740 SANTA CLARA DR
Second Line	:	SUITE 100-B
City	:	ROSEVILLE
State	:	CA
Zip	:	95661-2921
Country	:	US
Telephone Number	:	916-797-0406
Fax Number	:

Authorized Official
Title or Position	:	DMD/PRACTICE OWNER
Name	:	HAITHAM MOSLY
Credential	:
Telephone Number	:	916-797-0406

Provider Enumeration Date	:	05/05/2015
Last Update Date	:	05/05/2015

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