MEDICARE: RONALD MOOS 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
1	122300000X	Dentist	0445G	WI

General Provider Information

NPI Number	:	1972649952
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONALD MOOS DDS

Provider Business Mailing Address
First Line	:	328 FRANCES AVENUE
Second Line	:
City	:	CAMPBELLSPORT
State	:	WI
Zip	:	53010-0739
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	130 N FOND DU LAC AVE
Second Line	:
City	:	CAMPBELLSPORT
State	:	WI
Zip	:	53010-0739
Country	:	US
Telephone Number	:	920-533-8512
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	07/08/2007

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