1306977053 NPI number — PATRICK P MOSELEY FAMILY DENTISTRY

Table of content: REBECCA L. BROWN PT (NPI 1063491587)

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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