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NPI Code Detail

MEDICARE: LISA DIANE MOSS RDH

MEDICARE: LISA DIANE MOSS RDH
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
1124Q00000XDental Hygienist2006015980MO

General Provider Information

NPI Number : 1497105688
Entity Type Code : Individual
Provider Name (Legal Business Name) : LISA DIANE MOSS RDH
Provider Business Mailing Address
First Line : 5047 VIRGINIA AVE
Second Line : BLDG 500
City : FORT LEONARD WOOD
State : MO
Zip : 65473-9126
Country : US
Telephone Number : 573-596-0408
Fax Number : 573-596-0314
Provider Business Practice Location Address
First Line : 5047 VIRGINIA AVE
Second Line : BLDG 500
City : FORT LEONARD WOOD
State : MO
Zip : 65473-9126
Country : US
Telephone Number : 573-596-0408
Fax Number : 573-596-0314
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/17/2016
Last Update Date : 06/17/2016

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