Provider Demographics
NPI:1174889935
Name:MOSES, JUSTIN MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:MOSES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:953 S FRONTAGE RD W STE 104
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:CO
Mailing Address - Zip Code:81657-5709
Mailing Address - Country:US
Mailing Address - Phone:970-476-3991
Mailing Address - Fax:
Practice Address - Street 1:953 S FRONTAGE RD W STE 104
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-5709
Practice Address - Country:US
Practice Address - Phone:970-476-3991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODEN.002023901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program