1306977053 NPI number — PATRICK P MOSELEY FAMILY DENTISTRY

Table of content: (NPI 1306977053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306977053 NPI number — PATRICK P MOSELEY FAMILY DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATRICK P MOSELEY FAMILY DENTISTRY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1306977053
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 640
Provider Second Line Business Mailing Address:
305 NORTH SPRING STREET
Provider Business Mailing Address City Name:
FORDYCE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71742-0640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-352-5161
Provider Business Mailing Address Fax Number:
870-352-7510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 N SPRING ST
Provider Second Line Business Practice Location Address:
BOX 640
Provider Business Practice Location Address City Name:
FORDYCE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71742-3317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-352-5161
Provider Business Practice Location Address Fax Number:
870-352-7510
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MOSELEY
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
870-352-5161

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  2914 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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