1043332844 NPI number — KEVIN CARROLL MOSS DMD MS PLLC

Table of content: KEVIN CARROLL MOSS DMD MS PLLC (NPI 1043332844)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043332844 NPI number — KEVIN CARROLL MOSS DMD MS PLLC

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
MOSS

Provider First Name:
KEVIN

Provider Middle Name:
CARROLL

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:
DMD MS PLLC

Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043332844

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
07/08/2007

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5320 CORPORATE CENTER LOOP SE

Provider Second Line Business Mailing Address:
SUITE A

Provider Business Mailing Address City Name:
LACEY

Provider Business Mailing Address State Name:
WA

Provider Business Mailing Address Postal Code:
98503

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
360-491-7080

Provider Business Mailing Address Fax Number:
360-491-7105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5320 CORPORATE CENTER LOOP SE

Provider Second Line Business Practice Location Address:
SUITE A

Provider Business Practice Location Address City Name:
LACEY

Provider Business Practice Location Address State Name:
WA

Provider Business Practice Location Address Postal Code:
98503

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
360-491-7080

Provider Business Practice Location Address Fax Number:
360-491-7105

Provider Enumeration Date:
04/04/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 122300000X , with the licence number: 0700009204 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Taxonomy code: 1223X0400X , with the licence number: 0700009204 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .