1174828651 NPI number — MOSSMANN FAMILY DENTAL, PC

Table of content: (NPI 1174828651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174828651 NPI number — MOSSMANN FAMILY DENTAL, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOSSMANN FAMILY DENTAL, PC
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:
6
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:
1174828651
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1208
Provider Second Line Business Mailing Address:
240 MAIN STREET
Provider Business Mailing Address City Name:
SOUTH LANCASTER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01561-1208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-368-8474
Provider Business Mailing Address Fax Number:
978-368-8477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH LANCASTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01561-1208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-368-8474
Provider Business Practice Location Address Fax Number:
978-368-8477
Provider Enumeration Date:
01/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MOSSMANN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
ERICH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
978-368-8474

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  21269 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1902974074 . This is a "NPI TYPE I" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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